=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457766198
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL VANESSA CASTANEDA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2014
-----------------------------------------------------
Last Update Date | 12/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 S WELLS AVE
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89502-2550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-329-6300
-----------------------------------------------------
Fax | 775-348-3896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 E CHICAGO AVE # 152
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 125-065621
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------