Provider Demographics
NPI:1538165782
Name:CASTELLANET, MARK JOHN (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOHN
Last Name:CASTELLANET
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 1:3801 KATELLA AVE
Mailing Address - Street 2:STE 401
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3375
Mailing Address - Country:US
Mailing Address - Phone:562-598-3200
Mailing Address - Fax:562-799-3646
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:STE 401
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3375
Practice Address - Country:US
Practice Address - Phone:562-598-3200
Practice Address - Fax:562-799-3646
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGZ8642207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00GZ86420Medicaid
CAWGZ8642IMedicare ID - Type Unspecified
CA00GZ86420Medicaid