Provider Demographics
NPI:1649545542
Name:DECASTRO-SOSA, OMAR ANIBAL (IDC)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:ANIBAL
Last Name:DECASTRO-SOSA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 KELLY CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773
Mailing Address - Country:US
Mailing Address - Phone:580-917-7349
Mailing Address - Fax:
Practice Address - Street 1:NMCB ONE
Practice Address - Street 2:UNIT 60251
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34099
Practice Address - Country:US
Practice Address - Phone:228-871-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman