Basic Information
| Provider Information | |||||||||
| NPI: | 1538422316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTRO | ||||||||
| FirstName: | PABLO | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 241011 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952419511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093397435 | ||||||||
| FaxNumber: | 2093333054 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 W KETTLEMAN LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952424337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093348540 | ||||||||
| FaxNumber: | 2093682885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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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 | 208D00000X | 12389 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 12389 | 01 | PR | LICENSE | OTHER |