Provider Demographics
NPI:1407083256
Name:DE CASTRO, MAURICIO JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:JOSE
Last Name:DE CASTRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 FISHER ST
Mailing Address - Street 2:ROOM GG 700
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:228-376-3389
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:ROOM GG 700
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-3389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250567207SG0203X, 207SG0201X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics