Provider Demographics
NPI:1881647170
Name:DECASTRO, EDNA C (MD)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:C
Last Name:DECASTRO
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 1:13528 LIV 230
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-6398
Mailing Address - Country:US
Mailing Address - Phone:660-707-0280
Mailing Address - Fax:
Practice Address - Street 1:103 11TH ST
Practice Address - Street 2:STE 14
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-1676
Practice Address - Country:US
Practice Address - Phone:660-646-2682
Practice Address - Fax:660-646-2688
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF88480Medicare UPIN
268539Medicare ID - Type Unspecified