Provider Demographics
NPI:1346455748
Name:CHARLES W STINE OD PC
Entity Type:Organization
Organization Name:CHARLES W STINE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:CHANEL
Authorized Official - Last Name:KOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-687-3634
Mailing Address - Street 1:PO BOX 1360
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20118-1360
Mailing Address - Country:US
Mailing Address - Phone:540-687-3634
Mailing Address - Fax:540-687-3378
Practice Address - Street 1:4 PENDLETON ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:VA
Practice Address - Zip Code:20117
Practice Address - Country:US
Practice Address - Phone:540-687-3634
Practice Address - Fax:540-687-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000238152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192987OtherBLUECROSS BLUESHIELD
VA009231919Medicaid
VA0694647OtherAETNA HMO
VA320412OtherMAMSI
VA412947OtherUNITED HEALTHCARE
VA320412OtherALLIANCE
VAT78322Medicare UPIN
VAC10243Medicare PIN