Provider Demographics
NPI:1245220441
Name:NIEBLER, CHARLES G (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:NIEBLER
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 1:2205 N CALHOUN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5062
Mailing Address - Country:US
Mailing Address - Phone:262-786-4144
Mailing Address - Fax:262-796-4729
Practice Address - Street 1:2205 N CALHOUN RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5062
Practice Address - Country:US
Practice Address - Phone:262-786-4144
Practice Address - Fax:262-796-4729
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38572500Medicaid
T62877Medicare UPIN
WI38572500Medicaid