Provider Demographics
NPI:1801984562
Name:CASTRO-REVOREDO, IRIS ALTAGRACIA (MD)
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:ALTAGRACIA
Last Name:CASTRO-REVOREDO
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 1:13957 WOOLSEY RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-2246
Mailing Address - Country:US
Mailing Address - Phone:770-703-6601
Mailing Address - Fax:
Practice Address - Street 1:601 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4213
Practice Address - Country:US
Practice Address - Phone:770-467-6314
Practice Address - Fax:770-467-6324
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56984208M00000X
GA056984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine