Provider Demographics
NPI:1811991474
Name:CASTELLANOS, PETER W (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:CASTELLANOS
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 1:2225 TETON PLZ STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6494
Mailing Address - Country:US
Mailing Address - Phone:208-529-4300
Mailing Address - Fax:208-881-5121
Practice Address - Street 1:2225 TETON PLZ STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6494
Practice Address - Country:US
Practice Address - Phone:208-529-4300
Practice Address - Fax:208-881-5121
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010481792084N0402X
IDM101912084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200173520Medicaid
IN000000089466OtherANTHEM BXBS
IN000000089466OtherANTHEM BXBS
716700OMedicare PIN