Provider Demographics
NPI:1447208863
Name:PAEPKE, CHARLES W (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:PAEPKE
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 1:202 W BAY PLZ
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1786
Mailing Address - Country:US
Mailing Address - Phone:518-563-5460
Mailing Address - Fax:888-244-5003
Practice Address - Street 1:202 W BAY PLZ
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1786
Practice Address - Country:US
Practice Address - Phone:518-563-5460
Practice Address - Fax:888-244-5003
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003778-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010003778OtherEXCELLUS
NY000406946002OtherBLUE SHIELD NE NY
NYT26537Medicare UPIN
NY000406946002OtherBLUE SHIELD NE NY
NYRA7115Medicare ID - Type Unspecified