Provider Demographics
NPI:1720140890
Name:MCKELVEY, CHARLES GLEN III (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GLEN
Last Name:MCKELVEY
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3379 HIGHWAY 5
Mailing Address - Street 2:SUITE G
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-6928
Mailing Address - Country:US
Mailing Address - Phone:770-942-3111
Mailing Address - Fax:770-942-2298
Practice Address - Street 1:3379 HIGHWAY 5
Practice Address - Street 2:SUITE G
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6928
Practice Address - Country:US
Practice Address - Phone:770-942-3111
Practice Address - Fax:770-942-2298
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAOPT000910152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU18691Medicare UPIN
GA41ZCBXKMedicare ID - Type Unspecified