1063480655 NPI number — DR. PETER J CASTERELLA M.D.

Table of content: DR. PETER J CASTERELLA M.D. (NPI 1063480655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063480655 NPI number — DR. PETER J CASTERELLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTERELLA
Provider First Name:
PETER
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063480655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 17TH AVE
Provider Second Line Business Mailing Address:
680
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-320-5391
Provider Business Mailing Address Fax Number:
206-215-4550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 E JEFFERSON ST
Provider Second Line Business Practice Location Address:
610
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98122-5698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-320-5391
Provider Business Practice Location Address Fax Number:
206-215-4550
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  4963061-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806129500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002082167 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060065011 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: D4141 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116655700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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