Provider Demographics
NPI:1780643270
Name:DECASTRO, MARLON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:
Last Name:DECASTRO
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 1:500 DOYLE PARK DR
Mailing Address - Street 2:STE 303
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4558
Mailing Address - Country:US
Mailing Address - Phone:707-303-8300
Mailing Address - Fax:707-303-8301
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:STE. 303
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4558
Practice Address - Country:US
Practice Address - Phone:707-303-8300
Practice Address - Fax:707-303-8301
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23181207R00000X
CAC53594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC53594OtherCA LICENSE
SC23181OtherSTATE LICENSE
SC20-23181OtherDHEC
SC231813Medicaid
SC231813Medicaid
SC20-23181OtherDHEC
SC231813Medicaid