Provider Demographics
NPI:1114976420
Name:BRONAUGH, CHARDA P (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:CHARDA
Middle Name:P
Last Name:BRONAUGH
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 W FRANK AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3103
Mailing Address - Country:US
Mailing Address - Phone:936-632-1010
Mailing Address - Fax:936-632-3233
Practice Address - Street 1:1607 W FRANK AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3103
Practice Address - Country:US
Practice Address - Phone:936-632-1010
Practice Address - Fax:936-632-3233
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086517201Medicaid
TX925010Medicare UPIN
TX27897Medicare UPIN
TX0906860002Medicare NSC
TXOP1740Medicare UPIN
TX4007229Medicare UPIN
TX086517201Medicaid