Provider Demographics
NPI:1114927761
Name:BURNETT, CHARLENE N (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:N
Last Name:BURNETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 CARRIAGE HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3903
Mailing Address - Country:US
Mailing Address - Phone:731-668-4881
Mailing Address - Fax:731-668-5705
Practice Address - Street 1:214 CARRIAGE HOUSE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3903
Practice Address - Country:US
Practice Address - Phone:731-668-4881
Practice Address - Fax:731-668-5705
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT0D886152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3044859OtherBCBS
TN3598101Medicare PIN
TN3044859OtherBCBS
TN0227480001Medicare NSC
410036940Medicare ID - Type UnspecifiedRAILROAD MEDICARE