Provider Demographics
NPI:1689717993
Name:WHITE, CHARLEAN VIOLET (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLEAN
Middle Name:VIOLET
Last Name:WHITE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:CHARLEAN
Other - Middle Name:VIOLET
Other - Last Name:SPOTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-0338
Mailing Address - Country:US
Mailing Address - Phone:503-879-2236
Mailing Address - Fax:503-879-5089
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2236
Practice Address - Fax:503-879-5089
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2162T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU05547Medicare UPIN
OR111604Medicare ID - Type Unspecified