Provider Demographics
NPI:1962574137
Name:ASSELL, CHARLES C III (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:ASSELL
Suffix:III
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 1:525 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119-8333
Mailing Address - Country:US
Mailing Address - Phone:630-365-0702
Mailing Address - Fax:
Practice Address - Street 1:3800 E MAIN ST
Practice Address - Street 2:#114
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2457
Practice Address - Country:US
Practice Address - Phone:630-443-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09870Medicare ID - Type Unspecified
ILV01370Medicare UPIN