Healthcare Provider Details

I. General information

NPI: 1881046779
Provider Name (Legal Business Name): CHARLES ENGELBRECHT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7878 N 76TH ST
MILWAUKEE WI
53223-3914
US

IV. Provider business mailing address

5419 SILVER LAKE DR
WEST BEND WI
53095-8714
US

V. Phone/Fax

Practice location:
  • Phone: 414-586-5710
  • Fax:
Mailing address:
  • Phone: 262-305-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3426-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: