Provider Demographics
NPI:1669417150
Name:CHISUM, CHARLENE DOBBS (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:DOBBS
Last Name:CHISUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2544
Mailing Address - Country:US
Mailing Address - Phone:334-347-8900
Mailing Address - Fax:334-347-1480
Practice Address - Street 1:207 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2544
Practice Address - Country:US
Practice Address - Phone:334-347-8900
Practice Address - Fax:334-347-1480
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN01994152W00000X
ALS-921-TA-499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU78448Medicare UPIN
AL0626930001Medicare NSC