Healthcare Provider Details

I. General information

NPI: 1407854417
Provider Name (Legal Business Name): GORDON MICHAEL CASTLEBERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 HIGHWAY 182 W STE B
STARKVILLE MS
39759-9820
US

IV. Provider business mailing address

1207 HIGHWAY 182 W STE B
STARKVILLE MS
39759-9013
US

V. Phone/Fax

Practice location:
  • Phone: 662-324-1097
  • Fax: 662-324-2412
Mailing address:
  • Phone: 662-324-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number17324
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number17324
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: