Healthcare Provider Details

I. General information

NPI: 1164531471
Provider Name (Legal Business Name): CHARLES DAVID MEAD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

3201 NE 164TH ST
RIDGEFIELD WA
98642-8913
US

V. Phone/Fax

Practice location:
  • Phone: 360-571-3084
  • Fax: 360-571-3082
Mailing address:
  • Phone: 360-573-6805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOD00001440
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: