Provider Demographics
NPI:1124028493
Name:CROSSLIN, CHARLES G (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:CROSSLIN
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:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0444
Mailing Address - Country:US
Mailing Address - Phone:870-424-4900
Mailing Address - Fax:870-424-4979
Practice Address - Street 1:7345 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:GASSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72635
Practice Address - Country:US
Practice Address - Phone:870-435-3333
Practice Address - Fax:870-471-9029
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2326152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101232722Medicaid
AR49760Medicare ID - Type Unspecified