Provider Demographics
NPI:1275661647
Name:CHARLES, GLENN A (LDO)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:A
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8032 35TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-4815
Mailing Address - Country:US
Mailing Address - Phone:206-523-6676
Mailing Address - Fax:206-523-7900
Practice Address - Street 1:8032 35TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4815
Practice Address - Country:US
Practice Address - Phone:206-523-6676
Practice Address - Fax:206-523-7900
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00000615156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician