Provider Demographics
NPI:1578842464
Name:KEITH J. CASTLETON, OD, PLLC
Entity Type:Organization
Organization Name:KEITH J. CASTLETON, OD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASTLETON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-768-9316
Mailing Address - Street 1:1634 N 1200 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3572
Mailing Address - Country:US
Mailing Address - Phone:801-768-9316
Mailing Address - Fax:801-692-6784
Practice Address - Street 1:1634 N 1200 W
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3572
Practice Address - Country:US
Practice Address - Phone:801-768-9316
Practice Address - Fax:801-692-6784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5350538-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000074711Medicare PIN