MEDICARE: EDNA C DECASTRO M.D.

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	207R00000X	Internal Medicine Physician	106544	MO

General Provider Information

NPI Number	:	1881647170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDNA C DECASTRO M.D.

Provider Business Mailing Address
First Line	:	13528 LIV 230
Second Line	:
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-6398
Country	:	US
Telephone Number	:	660-707-0280
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 11TH ST
Second Line	:	STE 14
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-1676
Country	:	US
Telephone Number	:	660-646-2682
Fax Number	:	660-646-2688

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/08/2007

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