Provider Demographics
NPI:1699768333
Name:BURGESS, CHARLES J (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:BURGESS
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 1:1255 APPLETON RD
Mailing Address - Street 2:MENASHA
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1501
Mailing Address - Country:US
Mailing Address - Phone:920-722-6872
Mailing Address - Fax:920-722-6335
Practice Address - Street 1:1255 APPLETON RD
Practice Address - Street 2:MENASHA
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1501
Practice Address - Country:US
Practice Address - Phone:920-722-6872
Practice Address - Fax:920-722-6335
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38601700Medicaid
WIU68008Medicare UPIN
WI71600 0002Medicare ID - Type Unspecified
WI38601700Medicaid