Healthcare Provider Details

I. General information

NPI: 1346222320
Provider Name (Legal Business Name): CHARLES EDWARD HUCK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W 2ND ST
BLOOMINGTON IN
47403-2216
US

IV. Provider business mailing address

1011 W 2ND ST
BLOOMINGTON IN
47403-2216
US

V. Phone/Fax

Practice location:
  • Phone: 812-334-1213
  • Fax: 812-333-5039
Mailing address:
  • Phone: 812-334-1213
  • Fax: 812-333-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002173
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: