Provider Demographics
NPI:1649299652
Name:CASTANO, IVAN DARIO (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DARIO
Last Name:CASTANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4158
Mailing Address - Country:US
Mailing Address - Phone:305-556-3818
Mailing Address - Fax:305-557-7675
Practice Address - Street 1:4204 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4158
Practice Address - Country:US
Practice Address - Phone:305-556-3818
Practice Address - Fax:305-557-7675
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064767500Medicaid
FL02306Medicare PIN
FL064767500Medicaid