Basic Information
| Provider Information | |||||||||
| NPI: | 1962697730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECASTRO | ||||||||
| FirstName: | ISMARY | ||||||||
| MiddleName: | OJEDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 WATERS AVE STE 452 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123505909 | ||||||||
| FaxNumber: | 9123505914 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 WATERS AVE STE 452 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123505909 | ||||||||
| FaxNumber: | 9123505914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 067555 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 003122748A | 05 | GA | MEDICAID | P01048149 | 01 | GA | RAILROAD MEDICARE | OTHER |