Provider Demographics
NPI:1528171394
Name:CASTRO, IVAN JOSE (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:JOSE
Last Name:CASTRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3773
Mailing Address - Country:US
Mailing Address - Phone:407-628-1081
Mailing Address - Fax:407-628-1806
Practice Address - Street 1:300 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3773
Practice Address - Country:US
Practice Address - Phone:407-628-1081
Practice Address - Fax:407-628-1806
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E90172Medicare UPIN
FL12329YMedicare PIN