Provider Demographics
NPI:1275619876
Name:TODD, CHARLES L (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:TODD
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 1:552 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-5325
Mailing Address - Country:US
Mailing Address - Phone:501-329-6859
Mailing Address - Fax:
Practice Address - Street 1:552 LOCUST ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-5325
Practice Address - Country:US
Practice Address - Phone:501-329-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2476152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134909722Medicaid
AR134909722Medicaid
ARU71198Medicare UPIN