Provider Demographics
NPI:1831218387
Name:BROWN, CHARISSA C (RDO)
Entity type:Individual
Prefix:MS
First Name:CHARISSA
Middle Name:C
Last Name:BROWN
Suffix:
Gender:F
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:BELCHERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01007-0042
Mailing Address - Country:US
Mailing Address - Phone:413-323-1196
Mailing Address - Fax:413-323-1186
Practice Address - Street 1:142 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELCHERTOWN
Practice Address - State:MA
Practice Address - Zip Code:01007-9433
Practice Address - Country:US
Practice Address - Phone:413-323-1196
Practice Address - Fax:413-323-1186
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA3427152W00000X
MAMA2516152W00000X
MAMA4856156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA4856OtherEYE MED PROVIDER NUMBER
MA0338061Medicaid
MA0338061OtherMASS HEALTH PROVIDER NO.
MA4529500001Medicare ID - Type UnspecifiedSUPPLIER AND PIN NUMBER