Provider Demographics
NPI:1255318309
Name:DECASTRO, ANNAMARIE C (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNAMARIE
Middle Name:C
Last Name:DECASTRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANNAMARIE
Other - Middle Name:C
Other - Last Name:DECASTRO-HARTWEGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2020 ROTH DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3656
Mailing Address - Country:US
Mailing Address - Phone:314-822-1005
Mailing Address - Fax:
Practice Address - Street 1:2020 ROTH DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-3656
Practice Address - Country:US
Practice Address - Phone:314-822-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160484208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205448616Medicaid
MO205448608Medicaid
H40551Medicare UPIN
MO205448616Medicaid