Provider Demographics
NPI:1366446973
Name:HAMILTON, CHARLENE I (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:I
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E BELTLINE AVE NE
Mailing Address - Street 2:STE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6046
Mailing Address - Country:US
Mailing Address - Phone:616-949-2600
Mailing Address - Fax:616-954-0213
Practice Address - Street 1:750 E BELTLINE AVE NE
Practice Address - Street 2:STE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6046
Practice Address - Country:US
Practice Address - Phone:616-949-2600
Practice Address - Fax:616-954-0213
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003238152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4261079Medicaid
MI900D16683OtherBCBS
MI410043591OtherMEDICARE RR
MI0364980001Medicare NSC
MI410043591OtherMEDICARE RR
U34856Medicare UPIN