Provider Demographics
NPI:1962688317
Name:CASTELLANO, DOMINIC M (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:M
Last Name:CASTELLANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AESTHETIC FACIAL
Other - Middle Name:PLASTIC
Other - Last Name:SURGERY ASSOCIATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:SELECT PHYSICIANS ALLIANCE
Mailing Address - Street 2:10002 PRINCESS PALM AVE. STE 332
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-8327
Mailing Address - Country:US
Mailing Address - Phone:813-571-7184
Mailing Address - Fax:813-654-4695
Practice Address - Street 1:FLORIDA ENT & ALLERGY
Practice Address - Street 2:13015 SUMMERFIELD SQUARE DR
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7402
Practice Address - Country:US
Practice Address - Phone:813-879-8045
Practice Address - Fax:855-388-5356
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME101498207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1962659854OtherNPI