Provider Demographics
NPI:1619161221
Name:DE CASTRO, IGOR (MD)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
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 1:840 PINE ST STE 880
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7525
Mailing Address - Country:US
Mailing Address - Phone:478-743-7092
Mailing Address - Fax:478-743-6293
Practice Address - Street 1:840 PINE ST STE 880
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7525
Practice Address - Country:US
Practice Address - Phone:478-743-7092
Practice Address - Fax:478-743-6293
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5783174400000X
390200000X
GA79354207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program