Provider Demographics
NPI:1174628234
Name:CASTELLANOS-VIDAURRE, AUDRY (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDRY
Middle Name:
Last Name:CASTELLANOS-VIDAURRE
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 1:3225 AVIATION AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:COCONUT GROVE
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4741
Mailing Address - Country:US
Mailing Address - Phone:954-435-3220
Mailing Address - Fax:954-435-3667
Practice Address - Street 1:601 N FLAMINGO RD STE 311
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1010
Practice Address - Country:US
Practice Address - Phone:954-435-3220
Practice Address - Fax:954-435-3667
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088223207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35088223OtherLICENSE
FL277668500Medicaid