Provider Demographics
NPI:1194936831
Name:DECASTRO, JUSTINE DE LA ROSA (MD)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:DE LA ROSA
Last Name:DECASTRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-943-0846
Practice Address - Street 1:1254 YEAMANS HALL RD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410-2787
Practice Address - Country:US
Practice Address - Phone:843-554-8312
Practice Address - Fax:337-943-0846
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-07-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC32980207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC329807Medicaid
SCP01214786OtherRR-MEDICARE
SCSC11617126Medicare PIN
SCP01214786OtherRR-MEDICARE