1477901718 NPI number — ANGEL ERNESTO CASTRO PA-C

Table of content: ANGEL ERNESTO CASTRO PA-C (NPI 1477901718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477901718 NPI number — ANGEL ERNESTO CASTRO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTRO
Provider First Name:
ANGEL
Provider Middle Name:
ERNESTO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1477901718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
226 MILL HILL AVE, 3RD FL
Provider Second Line Business Mailing Address:
C/O NORTHEAST MEDICAL GROUP, INC.
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06610-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-789-4140
Provider Business Mailing Address Fax Number:
203-789-6617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 CHAPEL ST
Provider Second Line Business Practice Location Address:
VERDI 3 SOUTH 3021
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-4405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-789-4140
Provider Business Practice Location Address Fax Number:
203-789-6617
Provider Enumeration Date:
05/26/2016

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: 363AM0700X , with the licence number:  3618 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 3618 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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