Provider Demographics
NPI:1538116249
Name:DEL CASTILLO MATOS, ELAINE (PA)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:
Last Name:DEL CASTILLO MATOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73392
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0002
Mailing Address - Country:US
Mailing Address - Phone:937-293-0247
Mailing Address - Fax:937-293-0960
Practice Address - Street 1:2200 PHILADELPHIA DRIVE
Practice Address - Street 2:SUITE 555
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406
Practice Address - Country:US
Practice Address - Phone:937-275-5100
Practice Address - Fax:937-275-4587
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000388100OtherANTHEM
OHDEPA26391Medicare ID - Type Unspecified
Q62412Medicare UPIN