MEDICARE: CHARLESTON OCULOPLASTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician
2	207WX0200X	Ophthalmic Plastic and Reconstructive Surgery Physician

General Provider Information

NPI Number	:	1750087995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLESTON OCULOPLASTICS, LLC

Provider Business Mailing Address
First Line	:	302 WINGO WAY STE 202
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-5299
Country	:	US
Telephone Number	:	843-790-7582
Fax Number	:	843-790-7583

Provider Business Practice Location Address
First Line	:	302 WINGO WAY STE 203
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-2839
Country	:	US
Telephone Number	:	919-358-3474
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAKESH PATEL
Credential	:
Telephone Number	:	919-358-3474

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	12/22/2023

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