Provider Demographics
NPI:1548243611
Name:CASTELLANOS, MARIO
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:CASTELLANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EDGEWATER ST
Mailing Address - Street 2:6TH FLOOR - PAYER RELATIONS
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1008
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:242 MASON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3408
Practice Address - Country:US
Practice Address - Phone:718-226-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02023545Medicaid
NY02023545Medicaid
NY52C011Medicare PIN