Provider Demographics
NPI:1629843628
Name:CASTRO, ROBERTO
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:CASTRO
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 1:4230 HAMPTON ST APT 301
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2603
Mailing Address - Country:US
Mailing Address - Phone:551-200-3203
Mailing Address - Fax:
Practice Address - Street 1:4230 HAMPTON ST APT 301
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2603
Practice Address - Country:US
Practice Address - Phone:551-200-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010195-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty