Provider Demographics
NPI:1366614133
Name:TIEXEIRA, CHARLES FREDERICK (LDO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:TIEXEIRA
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2731
Mailing Address - Country:US
Mailing Address - Phone:716-874-4119
Mailing Address - Fax:
Practice Address - Street 1:2864 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2731
Practice Address - Country:US
Practice Address - Phone:716-874-4119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC005693-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician