Organization
GRAND TETON CHILD NEUROLOGY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PETER W CASTELLANOS MD (NEUROLOGIST)
(208) 529-4300
Entity
Organization
Contact information
Practice address
2225 TETON PLZ STE B, IDAHO FALLS, ID 83404-6494
(208) 529-4300
(208) 529-1627
Mailing address
2225 TETON PLZ STE B, IDAHO FALLS, ID 83404-6494
(208) 529-4300
(208) 881-5121
Taxonomy
Speciality
Code
Description
License number
State
2084N0402X
Neurology with Special Qualifications in Child Neurology Physician
Primary
—
—
251S00000X
Community/Behavioral Health Agency
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
77234
BLUE CROSS OF IDAHO
ID
05
—
807968700
—
ID
Enumeration date
10/28/2008
Last updated
08/17/2021
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