Provider Demographics
NPI:1528160025
Name:CIVIELLO, CHARLES A JR (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:CIVIELLO
Suffix:JR
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:PO BOX 8064
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-8064
Mailing Address - Country:US
Mailing Address - Phone:207-942-5597
Mailing Address - Fax:207-942-5597
Practice Address - Street 1:105 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5316
Practice Address - Country:US
Practice Address - Phone:207-942-5597
Practice Address - Fax:207-942-5597
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME621TA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MET31675Medicare UPIN
ME702865Medicare ID - Type Unspecified