Provider Demographics
NPI:1093992760
Name:CHARLES M. PLOURDE
Entity Type:Organization
Organization Name:CHARLES M. PLOURDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:PLOURDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-868-3341
Mailing Address - Street 1:67 MAIN ST
Mailing Address - Street 2:P.O. BOX 300
Mailing Address - City:VAN BUREN
Mailing Address - State:ME
Mailing Address - Zip Code:04785-1028
Mailing Address - Country:US
Mailing Address - Phone:207-868-3341
Mailing Address - Fax:207-868-3441
Practice Address - Street 1:67 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:ME
Practice Address - Zip Code:04785-1028
Practice Address - Country:US
Practice Address - Phone:207-868-3341
Practice Address - Fax:207-868-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0656152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0600230001Medicare NSC