Provider Demographics
NPI:1073601514
Name:CASTLEBERRY, KAREN Y (OD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:Y
Last Name:CASTLEBERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 ATLANTA HWY
Mailing Address - Street 2:SUITE 141
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7201
Mailing Address - Country:US
Mailing Address - Phone:706-613-6409
Mailing Address - Fax:706-613-5514
Practice Address - Street 1:3700 ATLANTA HWY
Practice Address - Street 2:#141
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7201
Practice Address - Country:US
Practice Address - Phone:706-613-6409
Practice Address - Fax:706-613-5514
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1324152WC0802X
MI3628152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00972771AMedicaid
GA10633OtherCOLE LOCATION #102007
GA101679Medicaid
GA41ZCFDDOtherCARRIER PROVIDER #
GA41ZCFDDOtherCARRIER PROVIDER #