Basic Information
| Provider Information | |||||||||
| NPI: | 1629029012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUND | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 GREENBELT RD | ||||||||
| Address2: | |||||||||
| City: | BERWYN HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207402257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013452053 | ||||||||
| FaxNumber: | 3014411752 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 GREENBELT RD | ||||||||
| Address2: | |||||||||
| City: | BERWYN HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207402257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013452053 | ||||||||
| FaxNumber: | 3014411752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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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 | TAO866 | MD | Y | Eye and Vision Services Providers | Optometrist | 152WV0400X | TAO866 | MD | N | Eye and Vision Services Providers | Optometrist | Vision Therapy |
ID Information
| ID | Type | State | Issuer | Description | 091730300 | 05 | MD | MEDICAID | 1003325 | 01 | MD | AETNA | OTHER | 271019 | 01 | MD | MAMSI/ALLIANCE | OTHER | 89160003 | 01 | DC | BC/BS | OTHER |