Provider Demographics
NPI:1588924252
Name:IRIS CASTRO-REVOREDO MD INC
Entity type:Organization
Organization Name:IRIS CASTRO-REVOREDO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASTRO-REVOREDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-510-7866
Mailing Address - Street 1:13957 WOOLSEY RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-2246
Mailing Address - Country:US
Mailing Address - Phone:770-510-7866
Mailing Address - Fax:770-603-1122
Practice Address - Street 1:13957 WOOLSEY RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-2246
Practice Address - Country:US
Practice Address - Phone:770-510-7866
Practice Address - Fax:770-603-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty