Basic Information
| Provider Information | |||||||||
| NPI: | 1679505044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTRO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DOMINIC | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 COMMERCE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685042 | ||||||||
| FaxNumber: | 6519685904 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685801 | ||||||||
| FaxNumber: | 6519685899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/01/2015 | ||||||||
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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 | 207X00000X | 005096 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 005096 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0004X | 43871 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 342593 | 05 | AZ | MEDICAID |