Provider Demographics
NPI:1972695880
Name:MOUNTCASTLE, DANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:MOUNTCASTLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5901 SUN BLVD
Mailing Address - Street 2:SUITE 113-A
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33715-1166
Mailing Address - Country:US
Mailing Address - Phone:727-865-6941
Mailing Address - Fax:727-867-2639
Practice Address - Street 1:5901 SUN BLVD
Practice Address - Street 2:SUITE 113-A
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33715-1166
Practice Address - Country:US
Practice Address - Phone:727-865-6941
Practice Address - Fax:727-867-2639
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME36289202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME36289OtherMEDICAL LICENSE NUMBER
FL039342800Medicaid
FL30270XMedicare ID - Type Unspecified
FL039342800Medicaid