Provider Demographics
NPI:1518031533
Name:CHARBENEAU, DAVID PATRICK (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PATRICK
Last Name:CHARBENEAU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60421 EYSTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-2021
Mailing Address - Country:US
Mailing Address - Phone:248-652-7113
Mailing Address - Fax:
Practice Address - Street 1:51450 SHELBY PARKWAY
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-997-0658
Practice Address - Fax:586-997-3567
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002586152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U77444Medicare UPIN
MIH27799002Medicare ID - Type Unspecified