Healthcare Provider Details

I. General information

NPI: 1114793155
Provider Name (Legal Business Name): CHARLOTTE IRENE SPADA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2547 E COMMERCE ST
SAN ANTONIO TX
78203-1907
US

IV. Provider business mailing address

9725 DATAPOINT DR # 69
SAN ANTONIO TX
78229-2384
US

V. Phone/Fax

Practice location:
  • Phone: 210-619-7020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11021
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number11021
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: