Provider Demographics
NPI:1740267129
Name:STINE, CHARLES DOUGLAS (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:STINE
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 1:4009 COMMUNITY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-4139
Mailing Address - Country:US
Mailing Address - Phone:715-241-2020
Mailing Address - Fax:715-241-9827
Practice Address - Street 1:4009 COMMUNITY CENTER DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4139
Practice Address - Country:US
Practice Address - Phone:715-241-2020
Practice Address - Fax:715-241-9827
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1909035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38521100Medicaid
U30933Medicare UPIN
WI38521100Medicaid