Provider Demographics
NPI:1841213576
Name:CASTLEBERRY, KIM A (OD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 COIT RD
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-5959
Mailing Address - Country:US
Mailing Address - Phone:972-985-1412
Mailing Address - Fax:972-964-5758
Practice Address - Street 1:5900 COIT RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-5959
Practice Address - Country:US
Practice Address - Phone:972-985-1412
Practice Address - Fax:972-964-5758
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3161TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100613202Medicaid
TXT12577Medicare UPIN
TX80199EMedicare PIN
TX5181590001Medicare NSC