Provider Demographics
NPI:1649277245
Name:WARDLE, CHARLES A (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:WARDLE
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 1:1426 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3720
Mailing Address - Country:US
Mailing Address - Phone:360-423-7650
Mailing Address - Fax:360-423-2346
Practice Address - Street 1:1426 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3720
Practice Address - Country:US
Practice Address - Phone:360-423-7650
Practice Address - Fax:360-423-2346
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA907152W00000X
OR1115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046902Medicaid
WA410004815OtherRAILROAD MEDICARE
WA2046902Medicaid
WA0765050001Medicare NSC
WAT02612Medicare UPIN