Healthcare Provider Details

I. General information

NPI: 1578535530
Provider Name (Legal Business Name): CHARLES THOMAS CARGILL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 BROOKTREE CT SUITE 220
WEXFORD PA
15090-9271
US

IV. Provider business mailing address

6400 BROOKTREE CT SUITE 220
WEXFORD PA
15090-9271
US

V. Phone/Fax

Practice location:
  • Phone: 724-935-5761
  • Fax: 724-935-2245
Mailing address:
  • Phone: 724-935-5761
  • Fax: 724-935-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG001176
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: