Basic Information
| Provider Information | |||||||||
| NPI: | 1902009251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTELLANOS | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | EDUARDO | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 56765 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD | ||||||||
| Address2: | SUITE 680 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024066017 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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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 | 207VG0400X | 42762 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | BP1-0026446 | 01 | INSTITUTIONAL PERMIT | OTHER | 588582 | 05 | AZ | MEDICAID |