Provider Demographics
NPI:1508206616
Name:CHARLES J KORTH OD, INC
Entity Type:Organization
Organization Name:CHARLES J KORTH OD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:KORTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-793-9987
Mailing Address - Street 1:1 W CALIFORNIA BLVD
Mailing Address - Street 2:STE 513
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3029
Mailing Address - Country:US
Mailing Address - Phone:626-793-9987
Mailing Address - Fax:
Practice Address - Street 1:1 W CALIFORNIA BLVD
Practice Address - Street 2:STE 513
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3029
Practice Address - Country:US
Practice Address - Phone:626-793-9987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9449 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty