Provider Demographics
NPI:1003898156
Name:FORNARA, CHARLES WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:FORNARA
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 1:224 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1164
Mailing Address - Country:US
Mailing Address - Phone:740-622-1484
Mailing Address - Fax:740-622-1540
Practice Address - Street 1:224 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1164
Practice Address - Country:US
Practice Address - Phone:740-622-1484
Practice Address - Fax:740-622-1540
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ713152W00000X
OH5622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2685018Medicaid
U26490Medicare UPIN
OH2685018Medicaid
OHCO9363991Medicare PIN