Provider Demographics
NPI:1962445189
Name:CHARBONNEAU, MARY UNDERBERG (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:UNDERBERG
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:UNDERBERG
Other - Last Name:ROSENBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:501 N NAVY BLVD
Mailing Address - Street 2:VISION CENTER
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-2011
Mailing Address - Country:US
Mailing Address - Phone:850-426-1747
Mailing Address - Fax:850-453-6617
Practice Address - Street 1:501 N NAVY BLVD
Practice Address - Street 2:VISION CENTER
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-2011
Practice Address - Country:US
Practice Address - Phone:850-426-1747
Practice Address - Fax:850-453-6617
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3406152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003499800Medicaid
FL003499800Medicaid