Provider Demographics
NPI:1437236775
Name:MCDONALD, CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:MCDONALD
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 MARLBORO AVE
Practice Address - Street 2:TRED AVON SQUARE
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-2729
Practice Address - Country:US
Practice Address - Phone:410-822-8686
Practice Address - Fax:410-822-7853
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD556909500Medicaid
MD174871ZEYMMedicare PIN
MD556909500Medicaid
352L823BMedicare PIN
MD174871ZERGMedicare PIN
350L815BMedicare PIN
MDT55918Medicare UPIN
MD410026569Medicare PIN