Provider Demographics
NPI:1194848309
Name:CASTELLON MIRANDA, JOSE E
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:E
Last Name:CASTELLON MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5004
Mailing Address - Street 2:PMB 301
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-0069
Mailing Address - Country:US
Mailing Address - Phone:939-928-9002
Mailing Address - Fax:939-928-9003
Practice Address - Street 1:71 CALLE COMERCIO
Practice Address - Street 2:
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698
Practice Address - Country:US
Practice Address - Phone:787-856-0844
Practice Address - Fax:787-267-5554
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12428208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR89014Medicare ID - Type Unspecified