Healthcare Provider Details

I. General information

NPI: 1548286909
Provider Name (Legal Business Name): VITA PARK EYE ASSOCIATES, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 GATEWAY DR
WAUPUN WI
53963-2276
US

IV. Provider business mailing address

140 GATEWAY DR
WAUPUN WI
53963-2276
US

V. Phone/Fax

Practice location:
  • Phone: 920-324-3191
  • Fax: 920-324-5026
Mailing address:
  • Phone: 920-324-3191
  • Fax: 920-324-5026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS CASTILLO
Title or Position: CORPORATION OFFICER
Credential: DO
Phone: 920-887-1151