1548286909 NPI number — VITA PARK EYE ASSOCIATES, SC

Table of content: (NPI 1548286909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548286909 NPI number — VITA PARK EYE ASSOCIATES, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITA PARK EYE ASSOCIATES, SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE WAUPUN EYE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548286909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 GATEWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUPUN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53963-2276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-324-3191
Provider Business Mailing Address Fax Number:
920-324-5026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 GATEWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUPUN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53963-2276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-324-3191
Provider Business Practice Location Address Fax Number:
920-324-5026
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASTILLO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATION OFFICER
Authorized Official Telephone Number:
920-887-1151

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 530337 . This is a "DEANCARE HMO LOCATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000016160 . This is a "OFFICE LOCATION" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: CP765 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 21310700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0593830001 . This is a "DEMPOS SUPPLIER NUMBER" identifier . This identifiers is of the category "OTHER".




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