Provider Demographics
NPI:1174677066
Name:TAYLOR, CHARLES ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:TAYLOR
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 1:4810 TECUMSEH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715
Mailing Address - Country:US
Mailing Address - Phone:812-475-0035
Mailing Address - Fax:812-477-4537
Practice Address - Street 1:6614 LOGAN DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715
Practice Address - Country:US
Practice Address - Phone:812-477-6700
Practice Address - Fax:812-477-2152
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001803A152W00000X
OH4807T1649152W00000X
KY0880DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V00887Medicare ID - Type Unspecified