Provider Demographics
NPI:1902009251
Name:CASTELLANOS, MARIO EDUARDO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:EDUARDO
Last Name:CASTELLANOS
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:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 680
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-6017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42762207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0026446OtherINSTITUTIONAL PERMIT
AZ588582Medicaid
BP1-0026446OtherINSTITUTIONAL PERMIT