Provider Demographics
NPI:1639216179
Name:CASTRO, MYRELLE BAQUIRAN (MD)
Entity Type:Individual
Prefix:
First Name:MYRELLE
Middle Name:BAQUIRAN
Last Name:CASTRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:2570 ROUTE 9W
Practice Address - Street 2:SUITE 4
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1323
Practice Address - Country:US
Practice Address - Phone:845-534-1505
Practice Address - Fax:845-534-1504
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253529207R00000X, 207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A400029004OtherMEDICARE