Basic Information
| Provider Information | |||||||||
| NPI: | 1962688317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTELLANO | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SURGERY ASSOCIATES | ||||||||
| OtherFirstName: | AESTHETIC FACIAL | ||||||||
| OtherMiddleName: | PLASTIC | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | SELECT PHYSICIANS ALLIANCE | ||||||||
| Address2: | 10002 PRINCESS PALM AVE. STE 332 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336198327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135717184 | ||||||||
| FaxNumber: | 8136544695 | ||||||||
| Practice Location | |||||||||
| Address1: | FLORIDA ENT & ALLERGY | ||||||||
| Address2: | 13015 SUMMERFIELD SQUARE DR | ||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335787402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138798045 | ||||||||
| FaxNumber: | 8553885356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2008 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | Other Service Providers | Specialist | 207YX0905X | ME101498 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1962659854 | 01 | NPI | OTHER |