Provider Demographics
NPI:1104525443
Name:MD SAMIR CASTELLON
Entity type:Organization
Organization Name:MD SAMIR CASTELLON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:CASTELLON CASTELLON
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD, MD
Authorized Official - Phone:305-522-7217
Mailing Address - Street 1:1141 SW 10TH ST REAR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3611
Mailing Address - Country:US
Mailing Address - Phone:305-522-7217
Mailing Address - Fax:907-313-1400
Practice Address - Street 1:1141 SW 10TH ST REAR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3611
Practice Address - Country:US
Practice Address - Phone:305-522-7217
Practice Address - Fax:907-313-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1104525443Medicaid
FL1104525443OtherOBAMACARE