Provider Demographics
NPI:1356467088
Name:PORCH, CHARLES EDWARD (OD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:PORCH
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 1:32 BLITHEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-8193
Mailing Address - Country:US
Mailing Address - Phone:850-479-1422
Mailing Address - Fax:850-479-1419
Practice Address - Street 1:2650 CREIGHTON RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7382
Practice Address - Country:US
Practice Address - Phone:850-479-1422
Practice Address - Fax:850-479-1419
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002346900Medicaid
FL002346900Medicaid
FL19106Medicare PIN