Provider Demographics
NPI:1275848962
Name:CRAIG, CHARLES MIKEL (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MIKEL
Last Name:CRAIG
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1613
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:220 N. IRONWOOD DR.
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615
Practice Address - Country:US
Practice Address - Phone:574-289-3937
Practice Address - Fax:574-280-7355
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5936152W00000X
IN18003759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201086990Medicaid
INM400042747Medicare PIN
IN160450037Medicare PIN
IN452570004Medicare PIN
IN201086990Medicaid
INP01148486Medicare PIN