Provider Demographics
NPI:1932129905
Name:MEAD, CHARLES R (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:MEAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1502 WOODLANE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2221
Mailing Address - Country:US
Mailing Address - Phone:651-735-9550
Mailing Address - Fax:651-735-9322
Practice Address - Street 1:1502 WOODLANE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2221
Practice Address - Country:US
Practice Address - Phone:651-735-9550
Practice Address - Fax:651-735-9322
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD1642000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123023900Medicaid
MN25841MEOtherBLUE CROSS BLUE SHIELD
MN2202721OtherMEDICA
MN110992OtherPATIENT CHOICE
MN21-15729OtherMEDICA MATERIALS
MN107964OtherUCARE MN
MN622001OtherPREFERRED ONE
MN410038747OtherRAILROAD MEDICARE
MN580610207OtherMEDICARE ID
MN110992OtherPATIENT CHOICE
MN0629830001Medicare NSC