Provider Demographics
NPI:1235165317
Name:CASTRO, SANDRA C (MD, FAAP, CHCQM)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:C
Last Name:CASTRO
Suffix:
Gender:F
Credentials:MD, FAAP, CHCQM
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:CASTRO
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, FAAP, CHCQM
Mailing Address - Street 1:350 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5001
Mailing Address - Country:US
Mailing Address - Phone:812-335-2434
Mailing Address - Fax:812-335-7604
Practice Address - Street 1:350 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5001
Practice Address - Country:US
Practice Address - Phone:812-335-2434
Practice Address - Fax:812-335-7604
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078458A208000000X
FLME502842080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07762OtherBLUE SHIELD
FL049285000Medicaid
VA1235165317Medicaid
E21417Medicare UPIN
TN103I374349Medicare PIN
FL07762UMedicare ID - Type Unspecified