Provider Demographics
NPI:1942267968
Name:WILFONG, CHARLES A (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:WILFONG
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 1:181 W CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4401
Mailing Address - Country:US
Mailing Address - Phone:843-662-0691
Mailing Address - Fax:843-678-9725
Practice Address - Street 1:181 W CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4401
Practice Address - Country:US
Practice Address - Phone:843-662-0691
Practice Address - Fax:843-678-9723
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD07909Medicaid
SCT244774813Medicare UPIN
SCD07909Medicaid