Provider Demographics
NPI:1962440792
Name:COLE, CHARLES HAROLD (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HAROLD
Last Name:COLE
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 1:2934 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3914
Mailing Address - Country:US
Mailing Address - Phone:574-269-5558
Mailing Address - Fax:574-269-3088
Practice Address - Street 1:2934 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3914
Practice Address - Country:US
Practice Address - Phone:574-269-5558
Practice Address - Fax:574-269-3088
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002042B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100159090Medicaid
INT83025Medicare UPIN
IN100159090Medicaid