Basic Information
| Provider Information | |||||||||
| NPI: | 1780643270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECASTRO | ||||||||
| FirstName: | MARLON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 DOYLE PARK DR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073038300 | ||||||||
| FaxNumber: | 7073038301 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 DOYLE PARK DR | ||||||||
| Address2: | STE. 303 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073038300 | ||||||||
| FaxNumber: | 7073038301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23181 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | C53594 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | C53594 | 01 | CA | CA LICENSE | OTHER | 23181 | 01 | SC | STATE LICENSE | OTHER | BD7901502 | 01 | DEA | OTHER | 20-23181 | 01 | SC | DHEC | OTHER | 231813 | 05 | SC | MEDICAID |