Provider Demographics
NPI:1871501510
Name:GLYNN, CHARLENE DUBOIS (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:DUBOIS
Last Name:GLYNN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-1802
Mailing Address - Country:US
Mailing Address - Phone:978-526-1368
Mailing Address - Fax:
Practice Address - Street 1:127 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-1802
Practice Address - Country:US
Practice Address - Phone:978-526-1368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0330060Medicaid
MAU80122Medicare UPIN
MADU W17305Medicare ID - Type Unspecified