Basic Information
| Provider Information | |||||||||
| NPI: | 1770873465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTRESANA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947738 | ||||||||
| FaxNumber: | 5034948776 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 TEXTILE WAY STE B | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305012543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789871499 | ||||||||
| FaxNumber: | 6789871498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2011 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD194315 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD2015-0914 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 85883 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.