Provider Demographics
NPI:1063298222
Name:CHACON, CAROLYN GISELE (OD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:GISELE
Last Name:CHACON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PERKASIE
Mailing Address - State:PA
Mailing Address - Zip Code:18944-1865
Mailing Address - Country:US
Mailing Address - Phone:267-810-5909
Mailing Address - Fax:
Practice Address - Street 1:417 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PERKASIE
Practice Address - State:PA
Practice Address - Zip Code:18944-1865
Practice Address - Country:US
Practice Address - Phone:267-810-5909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG004066152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist