Provider Demographics
NPI:1912905134
Name:CASTANEDA, MARCO A (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:A
Last Name:CASTANEDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12255 DEPAUL DRIVE
Mailing Address - Street 2:#675N
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-729-4271
Mailing Address - Fax:314-576-4755
Practice Address - Street 1:12255 DEPAUL DRIVE
Practice Address - Street 2:#675N
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-576-7213
Practice Address - Fax:314-576-4755
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4A34208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00015224OtherRAILROAD MEDICARE
MO166464OtherHEALTHLINK
P00015224OtherRAILROAD MEDICARE