1871503128 NPI number — WILLIE B CASTLEBERRY III O.D.

Table of content: WILLIE B CASTLEBERRY III O.D. (NPI 1871503128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871503128 NPI number — WILLIE B CASTLEBERRY III O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTLEBERRY
Provider First Name:
WILLIE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTLEBERRY
Provider Other First Name:
COLIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1871503128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 E GOLIAD AVE
Provider Second Line Business Mailing Address:
STE 256A
Provider Business Mailing Address City Name:
CROCKETT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75835-2140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-544-3763
Provider Business Mailing Address Fax Number:
936-544-7894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 MIDWESTERN PKWY
Provider Second Line Business Practice Location Address:
STE 256A
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76308-2823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-691-0224
Provider Business Practice Location Address Fax Number:
940-691-0225
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5767TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 80322Q . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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