Provider Demographics
NPI:1932425865
Name:CASTANEDA, JORGE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:CASTANEDA
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 1:1055 N DIXIE FWY STE 1
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6200
Mailing Address - Country:US
Mailing Address - Phone:386-416-0238
Mailing Address - Fax:386-423-0515
Practice Address - Street 1:1055 N DIXIE FWY STE 1
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6200
Practice Address - Country:US
Practice Address - Phone:386-416-0238
Practice Address - Fax:386-423-0515
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS157715207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114852900Medicaid
MS442277YJ5DMedicare PIN
MS04528386Medicaid
TNVAD000Medicare UPIN