Provider Demographics
NPI:1629029012
Name:MUND, CHARLES R (OD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:MUND
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 1:5701 GREENBELT RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2257
Mailing Address - Country:US
Mailing Address - Phone:301-345-2053
Mailing Address - Fax:301-441-1752
Practice Address - Street 1:5701 GREENBELT RD
Practice Address - Street 2:
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2257
Practice Address - Country:US
Practice Address - Phone:301-345-2053
Practice Address - Fax:301-441-1752
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTAO866152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD091730300Medicaid
MD1003325OtherAETNA
MD271019OtherMAMSI/ALLIANCE
DC89160003OtherBC/BS
MDT31256Medicare UPIN
MD469334E19Medicare ID - Type Unspecified