Provider Demographics
NPI:1871503128
Name:CASTLEBERRY, WILLIE B III (OD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:B
Last Name:CASTLEBERRY
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:COLIN
Other - Middle Name:
Other - Last Name:CASTLEBERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:711 E GOLIAD AVE
Mailing Address - Street 2:STE 256A
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-2140
Mailing Address - Country:US
Mailing Address - Phone:936-544-3763
Mailing Address - Fax:936-544-7894
Practice Address - Street 1:3111 MIDWESTERN PKWY
Practice Address - Street 2:STE 256A
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2823
Practice Address - Country:US
Practice Address - Phone:940-691-0224
Practice Address - Fax:940-691-0225
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5767TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80322QOtherBLUE CROSS BLUE SHIELD
TXU87554Medicare UPIN
TX80322QOtherBLUE CROSS BLUE SHIELD