Provider Demographics
NPI:1053368878
Name:CASTANEDA, CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:CASTANEDA
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 1:211 E OHIO ST APT 816
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3225
Mailing Address - Country:US
Mailing Address - Phone:312-399-8160
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-795-3159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062180A207P00000X
IL036115939207P00000X
TXN3541207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1053368878OtherTRICARE SOUTH
TX206743101Medicaid
TX1053368878OtherBCBSTX
IN01062180AOtherINDIANA LICENSE
IL036115939Medicaid
TX8CD082OtherBCBSTX
IN01062180AOtherINDIANA LICENSE
TX1053368878OtherBCBSTX
ILK35399Medicare PIN
TX8L20912Medicare PIN