Provider Demographics
NPI:1063412385
Name:CASTANEDA, EDWIN TATOY (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:TATOY
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 1:10324 OLD OCEAN CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1132
Mailing Address - Country:US
Mailing Address - Phone:410-629-0041
Mailing Address - Fax:410-629-0544
Practice Address - Street 1:10324 OLD OCEAN CITY BLVD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1132
Practice Address - Country:US
Practice Address - Phone:410-629-0041
Practice Address - Fax:410-629-0544
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDO046257207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD317601100Medicaid
MD13-4205990OtherEIN
MD317601100Medicaid
MD0845Medicare ID - Type Unspecified