Provider Demographics
NPI:1356656029
Name:NORWOOD, CHAKA CHANELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAKA
Middle Name:CHANELLE
Last Name:NORWOOD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CHAKA
Other - Middle Name:CHANELLE
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3950 AUSTIN PEAY HWY
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2516
Mailing Address - Country:US
Mailing Address - Phone:817-223-7294
Mailing Address - Fax:901-380-1276
Practice Address - Street 1:3950 AUSTIN PEAY HWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2516
Practice Address - Country:US
Practice Address - Phone:817-223-7294
Practice Address - Fax:901-380-1276
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS825152W00000X
TN3061152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08859508Medicaid
TN1528670Medicaid