Provider Demographics
NPI:1376548735
Name:HORNBERGER, CHARLES JOSEPH JR (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:HORNBERGER
Suffix:JR
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 1:3192 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-2846
Mailing Address - Country:US
Mailing Address - Phone:716-684-3124
Mailing Address - Fax:
Practice Address - Street 1:3192 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-2878
Practice Address - Country:US
Practice Address - Phone:716-684-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-10-13
Deactivation Date:2005-07-19
Deactivation Code:
Reactivation Date:2006-12-14
Provider Licenses
StateLicense IDTaxonomies
NYTUV005695152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U58316Medicare UPIN