MEDICARE: MR. CHARLES E HEACOCK OD

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
1	152W00000X	Optometrist	OP0002236	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942294905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES E HEACOCK OD

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	840 N STONE ST
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-3256
Country	:	US
Telephone Number	:	386-734-1766
Fax Number	:	386-740-7866

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	08/27/2021

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