Provider Demographics
NPI:1417202474
Name:NGO, CHARLIE VAN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:VAN
Last Name:NGO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:VAN
Other - Middle Name:CHARLIE
Other - Last Name:NGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:200 MINOR HL
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-0001
Mailing Address - Country:US
Mailing Address - Phone:510-642-2020
Mailing Address - Fax:
Practice Address - Street 1:200 MINOR HL
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-0001
Practice Address - Country:US
Practice Address - Phone:510-642-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002673152W00000X
CA14561 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist