Provider Demographics
NPI:1770025298
Name:TRUESDALE, CHAZ E (OD)
Entity type:Individual
Prefix:
First Name:CHAZ
Middle Name:E
Last Name:TRUESDALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:178 WAKELON ST
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-2403
Practice Address - Country:US
Practice Address - Phone:192-696-0329
Practice Address - Fax:919-269-0984
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2500152W00000X
VA0618002539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist