Provider Demographics
NPI:1154418051
Name:VITA PARK EYE ASSOCIATES, SC
Entity type:Organization
Organization Name:VITA PARK EYE ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-887-1151
Mailing Address - Street 1:240 CORPORATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916
Mailing Address - Country:US
Mailing Address - Phone:920-887-1151
Mailing Address - Fax:920-887-3353
Practice Address - Street 1:240 CORPORATE DRIVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-887-1151
Practice Address - Fax:920-887-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICP765OtherRAIL ROAD MEDICARE
WI21310700Medicaid
WI21310700Medicaid