=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386693257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES M KNUDSON O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15640 JOHN J DELANEY DR STE C
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-943-5110
-----------------------------------------------------
Fax | 704-943-4449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15640 JOHN J DELANEY DR STE C
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-943-5110
-----------------------------------------------------
Fax | 704-943-4449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2050
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------