1275677783 NPI number — DR. CHARLES A NASSAUER O.D.

Table of content: DR. CHARLES A NASSAUER O.D. (NPI 1275677783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275677783 NPI number — DR. CHARLES A NASSAUER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NASSAUER
Provider First Name:
CHARLES
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275677783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8614 WESTWOOD CENTER DR FL 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 NORTHSHORE BLVD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70460-6849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-641-1228
Provider Business Practice Location Address Fax Number:
985-643-1359
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  919183T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MN4126858 . This is a "HUMANA ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1380873 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LA9183 . This is a "EYE MED ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 721158167 . This is a "TAX PAY ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: LA99183 . This is a "VBA ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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