Healthcare Provider Details

I. General information

NPI: 1528160025
Provider Name (Legal Business Name): CHARLES A CIVIELLO JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 FOREST AVE
BANGOR ME
04401-5316
US

IV. Provider business mailing address

PO BOX 8064
BANGOR ME
04402-8064
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-5597
  • Fax: 207-942-5597
Mailing address:
  • Phone: 207-942-5597
  • Fax: 207-942-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number621TA
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: