Provider Demographics
NPI:1902862386
Name:RISSLER, CHARLES MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:RISSLER
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 1:1125 BALTUSTROL RUN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7067
Mailing Address - Country:US
Mailing Address - Phone:317-696-7851
Mailing Address - Fax:
Practice Address - Street 1:2373 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2717
Practice Address - Country:US
Practice Address - Phone:317-839-0713
Practice Address - Fax:317-837-4093
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001745A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100193380Medicaid
IN000000385426OtherANTHEM BCBS
IN000000385426OtherANTHEM BCBS
IN251270AMedicare PIN