Provider Demographics
NPI:1285661348
Name:BRAZEAL, CHARLES J (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:BRAZEAL
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 1:1326 JUDGE BROWN RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-7406
Mailing Address - Country:US
Mailing Address - Phone:706-518-7118
Mailing Address - Fax:
Practice Address - Street 1:2005 30TH ST
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3012
Practice Address - Country:US
Practice Address - Phone:334-768-7202
Practice Address - Fax:334-768-3550
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL369152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL126300Medicaid
AL000058199Medicare PIN
ALT69138Medicare UPIN
AL126300Medicaid