Provider Demographics
NPI:1679655716
Name:KESNER, CHARLES EDDIE II (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDDIE
Last Name:KESNER
Suffix:II
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 1:307 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282
Mailing Address - Country:US
Mailing Address - Phone:480-967-5710
Mailing Address - Fax:480-967-2845
Practice Address - Street 1:3900 W RAY RD
Practice Address - Street 2:SUTIE #1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226
Practice Address - Country:US
Practice Address - Phone:480-820-9880
Practice Address - Fax:480-820-0232
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
82264Medicare ID - Type Unspecified
U98335Medicare UPIN
AZZWDBTZMedicare PIN