Basic Information
Provider Information
NPI: 1003002106
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CASTRO CORDOBA
FirstName: JUAN LUIS
MiddleName:  
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Mailing Information
Address1: 2640 FOREST HILL BLVD
Address2:  
City: WEST PALM BEACH
State: FL
PostalCode: 334065931
CountryCode: US
TelephoneNumber: 5016168411
FaxNumber:  
Practice Location
Address1: 2640 FOREST HILL BLVD
Address2:  
City: WEST PALM BEACH
State: FL
PostalCode: 334065931
CountryCode: US
TelephoneNumber: 5016168411
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/21/2007
LastUpdateDate: 09/21/2016
NPIDeactivationReasonCode:  
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NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: N
IsOrganizationSubpart:  
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AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084P0804XME126716FLY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
2084P0804XE-6076ARN Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
2084P0804X045551CTN Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry

No ID Information.


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