Provider Demographics
NPI:1578535530
Name:CARGILL, CHARLES THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:CARGILL
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 1:6400 BROOKTREE CT
Mailing Address - Street 2:SUITE 220
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9271
Mailing Address - Country:US
Mailing Address - Phone:724-935-5761
Mailing Address - Fax:724-935-2245
Practice Address - Street 1:6400 BROOKTREE CT
Practice Address - Street 2:SUITE 220
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9271
Practice Address - Country:US
Practice Address - Phone:724-935-5761
Practice Address - Fax:724-935-2245
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001176152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA251429756Medicare UPIN