Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | 0101250567 | VA |
NPI | 1407083256 |
---|---|
Provider Name | Dr. Mauricio Jose De Castro |
First Address | Keesler Afb, MS 39534-2508 |
Second Address | Keesler Afb, MS 39534-2508 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2009 |
Last Update Date | 18/04/2018 |