Provider Demographics
NPI:1619028115
Name:PLOURDE, CHARLES M (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:PLOURDE
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 1:67 MAIN ST
Mailing Address - Street 2:P.O. BOX 300
Mailing Address - City:VAN BUREN
Mailing Address - State:ME
Mailing Address - Zip Code:04785-1028
Mailing Address - Country:US
Mailing Address - Phone:207-868-3341
Mailing Address - Fax:207-868-3441
Practice Address - Street 1:67 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:ME
Practice Address - Zip Code:04785-1028
Practice Address - Country:US
Practice Address - Phone:207-868-3341
Practice Address - Fax:207-868-3441
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT656152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME111810000Medicaid
T31708Medicare UPIN
ME707361Medicare PIN