Healthcare Provider Details

I. General information

NPI: 1619028115
Provider Name (Legal Business Name): CHARLES M. PLOURDE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 MAIN ST
VAN BUREN ME
04785-1028
US

IV. Provider business mailing address

67 MAIN ST P.O. BOX 300
VAN BUREN ME
04785-1028
US

V. Phone/Fax

Practice location:
  • Phone: 207-868-3341
  • Fax: 207-868-3441
Mailing address:
  • Phone: 207-868-3341
  • Fax: 207-868-3441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPT656
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT656
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: