Provider Demographics
NPI:1306120746
Name:CASTELLON, ODALIS (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:ODALIS
Middle Name:
Last Name:CASTELLON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 JOHNSON STREET
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021
Mailing Address - Country:US
Mailing Address - Phone:954-964-4113
Mailing Address - Fax:954-963-8121
Practice Address - Street 1:3449 JOHNSON STREET
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-964-4113
Practice Address - Fax:954-963-8121
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101779363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical