Provider Demographics
NPI:1407854417
Name:CASTLEBERRY, GORDON MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:MICHAEL
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 HIGHWAY 182 W
Mailing Address - Street 2:STE B
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-9013
Mailing Address - Country:US
Mailing Address - Phone:662-324-1097
Mailing Address - Fax:
Practice Address - Street 1:1207 HIGHWAY 182 W STE B
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-9820
Practice Address - Country:US
Practice Address - Phone:662-324-1097
Practice Address - Fax:662-324-2412
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17324174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07481088Medicaid
MS340000252Medicare ID - Type UnspecifiedUROLOGIST
MS07481088Medicaid
MSC03014Medicare ID - Type UnspecifiedCLINIC CODE