Provider Demographics
NPI:1306950100
Name:CASTELLANO, MARIA C (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:C
Last Name:CASTELLANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 N OAK ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2576
Mailing Address - Country:US
Mailing Address - Phone:229-588-4688
Mailing Address - Fax:229-588-4468
Practice Address - Street 1:2418 N OAK ST
Practice Address - Street 2:SUITE G
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2576
Practice Address - Country:US
Practice Address - Phone:229-588-4688
Practice Address - Fax:229-588-4468
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045419207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA674370634AMedicaid
GA10BDHJDMedicare ID - Type Unspecified
GA674370634AMedicaid