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NPI Code Detail

MEDICARE: CHARLES L. HEATON, MD, PA

MEDICARE: CHARLES L. HEATON, MD, PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1156FX1800XOptician

General Provider Information

NPI Number : 1649575291
Entity Type Code : Organization
Provider Name (Legal Business Name) : CHARLES L. HEATON, MD, PA
Provider Business Mailing Address
First Line : 3415 GOLDEN RD
Second Line :
City : TYLER
State : TX
Zip : 75701-8355
Country : US
Telephone Number : 903-526-0444
Fax Number : 903-526-2051
Provider Business Practice Location Address
First Line : 1205 N 6TH ST
Second Line :
City : LONGVIEW
State : TX
Zip : 75601-5539
Country : US
Telephone Number : 903-234-0771
Fax Number : 903-234-0775
Authorized Official
Title or Position : CREDENTIALING SPECIALIST
Name : JUDITH HODGES-ODOM
Credential :
Telephone Number : 903-526-0444
Provider Enumeration Date : 01/12/2011
Last Update Date : 08/09/2023

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