MEDICARE: DR. NICHOLAS A CASTELLANO OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2016017805	MO

General Provider Information

NPI Number	:	1669821062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS A CASTELLANO OD

Provider Business Mailing Address
First Line	:	2511 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2308
Country	:	US
Telephone Number	:	314-863-0000
Fax Number	:	314-961-1041

Provider Business Practice Location Address
First Line	:	2511 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2308
Country	:	US
Telephone Number	:	314-863-0000
Fax Number	:	314-961-1041

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	06/07/2016

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