Provider Demographics
NPI:1548286909
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 1:140 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2276
Mailing Address - Country:US
Mailing Address - Phone:920-324-3191
Mailing Address - Fax:920-324-5026
Practice Address - Street 1:140 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2276
Practice Address - Country:US
Practice Address - Phone:920-324-3191
Practice Address - Fax:920-324-5026
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
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
530337OtherDEANCARE HMO LOCATION
WI000016160OtherOFFICE LOCATION
WICP765OtherRAIL ROAD MEDICARE
WI21310700Medicaid
0593830001OtherDEMPOS SUPPLIER NUMBER
WI21310700Medicaid
0593830001OtherDEMPOS SUPPLIER NUMBER