Healthcare Provider Details

I. General information

NPI: 1538144217
Provider Name (Legal Business Name): CHARLES A BRIZIUS OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 LINCOLN AVE
EVANSVILLE IN
47714-1628
US

IV. Provider business mailing address

2700 LINCOLN AVE
EVANSVILLE IN
47714-1628
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-8696
  • Fax: 812-477-1874
Mailing address:
  • Phone: 812-477-8696
  • Fax: 812-477-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number56000053A
License Number StateIN

VIII. Authorized Official

Name: DR. STACEY O EMBRY
Title or Position: SEC/TREAS
Credential: OD
Phone: 812-477-8696