Provider Demographics
NPI:1093735011
Name:PHILLIPS, CHARLES W (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 W WADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5457
Mailing Address - Country:US
Mailing Address - Phone:432-689-0323
Mailing Address - Fax:432-689-2916
Practice Address - Street 1:4311 W WADLEY AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-5457
Practice Address - Country:US
Practice Address - Phone:432-689-0323
Practice Address - Fax:432-689-2916
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2745TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019790701Medicaid
TX0778310001Medicare NSC
TXT15284Medicare UPIN