Provider Demographics
NPI:1154466449
Name:HAYNES, CHARLENE (OD)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:HAYNES
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 1:16793 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2349
Mailing Address - Country:US
Mailing Address - Phone:210-545-4772
Mailing Address - Fax:210-545-5350
Practice Address - Street 1:16793 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2349
Practice Address - Country:US
Practice Address - Phone:210-545-4772
Practice Address - Fax:210-545-5350
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4268TG152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6552490001Medicare NSC
TXU11949Medicare UPIN