Provider Demographics
NPI:1497801633
Name:DALE, CHARLES ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:DALE
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 1:3002 HARBORVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1962
Mailing Address - Country:US
Mailing Address - Phone:253-851-2050
Mailing Address - Fax:
Practice Address - Street 1:3002 HARBORVIEW DR
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1962
Practice Address - Country:US
Practice Address - Phone:253-851-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1642152W00000X
OR1758ATI152W00000X
WY169152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2004588Medicaid
WA0332830001Medicare NSC
WA410008041Medicare ID - Type UnspecifiedTRAVELER'S MEDICARE
WATO2236Medicare UPIN
WA2004588Medicaid
WA001001468Medicare ID - Type UnspecifiedPIERCE COUNTY MEDICARE NO
WA000200619Medicare ID - Type UnspecifiedMASON COUNTY MEDICARE NO.