Provider Demographics
NPI:1003175126
Name:CASTRO WAGNER, JOHANA BEATRIZ (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANA
Middle Name:BEATRIZ
Last Name:CASTRO WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 SEMINOLE BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3239
Mailing Address - Country:US
Mailing Address - Phone:727-397-8557
Mailing Address - Fax:727-397-4459
Practice Address - Street 1:11200 SEMINOLE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3239
Practice Address - Country:US
Practice Address - Phone:727-397-8557
Practice Address - Fax:727-397-4459
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124372207K00000X
FLME 124372208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology