Provider Demographics
NPI:1710920897
Name:CASTANEDA, THADDAEUS R (MD)
Entity Type:Individual
Prefix:DR
First Name:THADDAEUS
Middle Name:R
Last Name:CASTANEDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 S JOHN SIMS PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1271
Mailing Address - Country:US
Mailing Address - Phone:850-729-3300
Mailing Address - Fax:850-729-3100
Practice Address - Street 1:143 S. JOHN SIMS PRKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580
Practice Address - Country:US
Practice Address - Phone:850-729-3300
Practice Address - Fax:850-729-3100
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2777061 00Medicaid
FLH16674Medicare UPIN
FL2777061 00Medicaid