Healthcare Provider Details

I. General information

NPI: 1316937568
Provider Name (Legal Business Name): CHARLES P HADDAD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E MARKET ST
SOMERVILLE TN
38068-1407
US

IV. Provider business mailing address

PO BOX 489
SOMERVILLE TN
38068-0489
US

V. Phone/Fax

Practice location:
  • Phone: 901-465-3955
  • Fax: 901-465-6797
Mailing address:
  • Phone: 901-465-3955
  • Fax: 901-465-6797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT377
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: