Provider Demographics
NPI:1982757480
Name:DR CHARLES J BRAZEAL P C
Entity Type:Organization
Organization Name:DR CHARLES J BRAZEAL P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-863-2221
Mailing Address - Street 1:950 HIGHWAY 431 STE 4
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-7314
Mailing Address - Country:US
Mailing Address - Phone:334-863-2221
Mailing Address - Fax:334-863-2319
Practice Address - Street 1:950 HIGHWAY 431 STE 4
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274-7314
Practice Address - Country:US
Practice Address - Phone:334-863-2221
Practice Address - Fax:334-863-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS407TA017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL126302Medicaid
AL000058200Medicare PIN
0151060002Medicare NSC
ALT69138Medicare UPIN