Provider Demographics
NPI:1952452518
Name:CASTANEDA- VAN WYK, IRIS (MD)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:
Last Name:CASTANEDA- VAN WYK
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 1:1532 ANACAPA ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-1929
Mailing Address - Country:US
Mailing Address - Phone:805-892-4141
Mailing Address - Fax:805-832-6433
Practice Address - Street 1:1532 ANACAPA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-1929
Practice Address - Country:US
Practice Address - Phone:805-892-4141
Practice Address - Fax:805-832-6433
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71051208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A710510Medicaid
CAA710510OtherLICENSE NUMBER