Provider Demographics
NPI:1457766198
Name:CASTANEDA, CRYSTAL VANESSA (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:VANESSA
Last Name:CASTANEDA
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 1:225 E CHICAGO AVE # 152
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 S WELLS AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2550
Practice Address - Country:US
Practice Address - Phone:775-329-6300
Practice Address - Fax:775-348-3896
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-065621208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125-065621Medicaid
IL$$$$$$$$$Medicaid