Provider Demographics
NPI:1285689877
Name:BURNS, CHARLOTTE LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:LEIGH
Last Name:BURNS
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 1:5920 ENCORE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-4760
Mailing Address - Country:US
Mailing Address - Phone:972-607-5978
Mailing Address - Fax:
Practice Address - Street 1:5920 ENCORE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4760
Practice Address - Country:US
Practice Address - Phone:972-607-5978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07352T152W00000X
WI2654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38707300Medicaid
WIUS7952Medicare UPIN
WI000087921Medicare ID - Type Unspecified