MEDICARE: DR. CHARLES STEPHEN MCQUAIG II O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT002029	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41ZCFCD	OTHER	GA	PTAN

General Provider Information

NPI Number	:	1457356974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES STEPHEN MCQUAIG II O.D.

Provider Business Mailing Address
First Line	:	111 FIELDSTONE DRIVE
Second Line	:	SUITE 100
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061
Country	:	US
Telephone Number	:	478-453-9333
Fax Number	:	478-453-7760

Provider Business Practice Location Address
First Line	:	111 FIELDSTONE DRIVE
Second Line	:	SUITE 100
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061
Country	:	US
Telephone Number	:	478-453-9333
Fax Number	:	478-453-7760

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	01/28/2015

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