Provider Demographics
NPI:1235187923
Name:ASTRA MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:ASTRA MEDICAL CLINIC, PC
Other - Org Name:OPTUM PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-480-2550
Mailing Address - Street 1:13613 W CAMINO DEL SOL
Mailing Address - Street 2:ST 5
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-4480
Mailing Address - Country:US
Mailing Address - Phone:623-584-7154
Mailing Address - Fax:
Practice Address - Street 1:13613 W CAMINO DEL SOL
Practice Address - Street 2:ST 5
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-4480
Practice Address - Country:US
Practice Address - Phone:623-584-7154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2023-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF63399Medicare UPIN
AZZ20050Medicare PIN