Provider Demographics
NPI:1467471201
Name:CASTELLON, CARLOS H (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:H
Last Name:CASTELLON
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 1:152 NW OTTER CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-7252
Mailing Address - Country:US
Mailing Address - Phone:386-752-4199
Mailing Address - Fax:
Practice Address - Street 1:152 NW OTTER CT
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-7252
Practice Address - Country:US
Practice Address - Phone:386-752-4199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46096207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43074900Medicaid
FL0430749-00Medicaid
FL12072NOtherMEDICARE
D85031Medicare UPIN
FL0430749-00Medicaid
FL12072NOtherMEDICARE