Provider Demographics
NPI:1851356844
Name:CHARLOTTE OPHTHALMOLOGY CLINIC P.A.
Entity Type:Organization
Organization Name:CHARLOTTE OPHTHALMOLOGY CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-895-8200
Mailing Address - Street 1:16610 BIRKDALE COMMONS PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5646
Mailing Address - Country:US
Mailing Address - Phone:704-895-8200
Mailing Address - Fax:704-997-8708
Practice Address - Street 1:16610 BIRKDALE COMMONS PKWY STE A
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5646
Practice Address - Country:US
Practice Address - Phone:704-895-8200
Practice Address - Fax:704-997-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32307207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4262680001Medicare NSC