Provider Demographics
NPI:1124545413
Name:CHARLES L. HEATON , M.D. P.A.
Entity Type:Organization
Organization Name:CHARLES L. HEATON , M.D. P.A.
Other - Org Name:HEATON EYE ASSOICATES OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-526-0444
Mailing Address - Street 1:3415 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8355
Mailing Address - Country:US
Mailing Address - Phone:903-526-0444
Mailing Address - Fax:903-526-2051
Practice Address - Street 1:3415 GOLDEN RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8355
Practice Address - Country:US
Practice Address - Phone:903-526-0444
Practice Address - Fax:903-526-2051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLES L. HEATON , M.D. P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-28
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier