Basic Information
| Provider Information | |||||||||
| NPI: | 1174744155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARLTON | ||||||||
| FirstName: | WESLEY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 633 GOV CARLOS CAMACHO RD. | ||||||||
| Address2: | ST.LUCY'SEYE CLINIC SUITE 103 GUAM MEDICAL PLASA | ||||||||
| City: | TAMUNING | ||||||||
| State: | GU | ||||||||
| PostalCode: | 96913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6716475829 | ||||||||
| FaxNumber: | 6716475830 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHIEF EDDIE HOFFMAN HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 123 | AK | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OL-046 | GU | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | OD11233 | 05 | AK | MEDICAID |