Basic Information
| Provider Information | |||||||||
| NPI: | 1093709479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTRO | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | MANUEL PEREZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 COATES DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511400 | ||||||||
| FaxNumber: | 8456511512 | ||||||||
| Practice Location | |||||||||
| Address1: | 2570 ROUTE 9W | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511400 | ||||||||
| FaxNumber: | 8456511512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 002190 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 253533 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 00472931 | 05 | NY | MEDICAID | 331832 | 01 | MEDICARE | OTHER | A400036561 | 01 | MEDICARE | OTHER |