Healthcare Provider Details

I. General information

NPI: 1053303495
Provider Name (Legal Business Name): CHALRES ALBERT MCBRIDE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12370 SW 1ST ST
BEAVERTON OR
97005-2847
US

IV. Provider business mailing address

12370 SW 1ST ST
BEAVERTON OR
97005-2847
US

V. Phone/Fax

Practice location:
  • Phone: 503-644-3614
  • Fax: 503-646-4069
Mailing address:
  • Phone: 503-644-3614
  • Fax: 503-646-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2542T
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: