=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730239310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIRO DE JESUS CASTROLONDONO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 12/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 N BEAVER ST
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-214-2920
-----------------------------------------------------
Fax | 928-214-2925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 N BEAVER ST PAYER CREDENTIALING
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-773-2559
-----------------------------------------------------
Fax | 928-213-6292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 170100000X
-----------------------------------------------------
Taxonomy Name | Ph.D. Medical Genetics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 42662
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------