Provider Demographics
NPI:1255818993
Name:CASTELLON, KERRYN (DO)
Entity type:Individual
Prefix:
First Name:KERRYN
Middle Name:
Last Name:CASTELLON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KERRYN
Other - Middle Name:
Other - Last Name:CASTELLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:55 SUDDERTH ST
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3335
Mailing Address - Country:US
Mailing Address - Phone:678-458-5095
Mailing Address - Fax:
Practice Address - Street 1:55 SUDDERTH ST
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3335
Practice Address - Country:US
Practice Address - Phone:678-458-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3747A0650X
GALDO002538156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA824147685Medicaid