Provider Demographics
NPI:1447205570
Name:DEMBOWSKI, CHARLES (OD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:DEMBOWSKI
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 1:4 COMMERCE LANE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:167 POLK ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-786-0983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005520152W00000X
NYOV005520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NYAA0564Medicare PIN
NYCC5989Medicare ID - Type UnspecifiedOPTOMETRY
NY01995615Medicaid