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General NPI Number Information
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NPI Number | 1548286909
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Entity Type | Organization
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Legal Business Name | VITA PARK EYE ASSOCIATES, SC
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 04/21/2021
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Provider Practice Location Address
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Address Line | 140 GATEWAY DR
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City | WAUPUN
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State | WI
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Zip | 53963-2276
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Country | US
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Telephone | 920-324-3191
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Fax | 920-324-5026
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Provider Business Mailing Address
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Address Line | 140 GATEWAY DR
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City | WAUPUN
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State | WI
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Zip | 53963-2276
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Country | US
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Telephone | 920-324-3191
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Fax | 920-324-5026
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Authorized Official
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Title or Position | CORPORATION OFFICER
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Name | THOMAS CASTILLO
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Credential | DO
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Telephone | 920-887-1151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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