Provider Demographics
NPI:1447276894
Name:VITA PARK EYE ASSOCIATES, SC
Entity type:Organization
Organization Name:VITA PARK EYE ASSOCIATES, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-887-1151
Mailing Address - Street 1:240 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3115
Mailing Address - Country:US
Mailing Address - Phone:920-887-1151
Mailing Address - Fax:920-887-3353
Practice Address - Street 1:240 CORPORATE DRIVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3115
Practice Address - Country:US
Practice Address - Phone:920-887-1151
Practice Address - Fax:920-887-3353
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITA PARK EYE ASSOCIATES, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-15
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0593830002OtherDEPMOS SUPPLIER
000016160OtherOFFICE LOCATION
WICP765OtherRAIL ROAD MEDICARE
WI21310700Medicaid
519075OtherDEAN CARE HMO LOCATION
WICP765OtherRAIL ROAD MEDICARE
WI000016160Medicare ID - Type Unspecified
0593830002Medicare NSC