Basic Information
| Provider Information | |||||||||
| NPI: | 1447276894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VITA PARK EYE ASSOCIATES, SC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BEAVER DAM EYE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 240 CORPORATE DR | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208871151 | ||||||||
| FaxNumber: | 9208873353 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 CORPORATE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208871151 | ||||||||
| FaxNumber: | 9208873353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASTILLO | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9208871151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VITA PARK EYE ASSOCIATES, SC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0593830002 | 01 | DEPMOS SUPPLIER | OTHER | 000016160 | 01 | OFFICE LOCATION | OTHER | CP765 | 01 | WI | RAIL ROAD MEDICARE | OTHER | 21310700 | 05 | WI | MEDICAID | 519075 | 01 | DEAN CARE HMO LOCATION | OTHER |