Provider Demographics
NPI:1447433438
Name:COLIN CASTLEBERRY PC
Entity type:Organization
Organization Name:COLIN CASTLEBERRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:940-691-0224
Mailing Address - Street 1:3111 MIDWESTERN PKWY
Mailing Address - Street 2:SUITE 256A
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2823
Mailing Address - Country:US
Mailing Address - Phone:940-691-0224
Mailing Address - Fax:940-691-0225
Practice Address - Street 1:3111 MIDWESTERN PKWY
Practice Address - Street 2:SUITE 256A
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2823
Practice Address - Country:US
Practice Address - Phone:940-691-0224
Practice Address - Fax:940-691-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5767TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU87554Medicare UPIN
TX00175SMedicare PIN