Provider Demographics
NPI:1033295639
Name:CHARLES TODD, PA
Entity Type:Organization
Organization Name:CHARLES TODD, PA
Other - Org Name:PARK-TODD EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:501-329-6859
Mailing Address - Street 1:552 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-5325
Mailing Address - Country:US
Mailing Address - Phone:501-329-6859
Mailing Address - Fax:501-329-6850
Practice Address - Street 1:552 LOCUST ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-5325
Practice Address - Country:US
Practice Address - Phone:501-329-6859
Practice Address - Fax:501-329-6850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135733722Medicaid
AR5C122Medicare ID - Type UnspecifiedCLINIC
AR5192860001Medicare NSC