Provider Demographics
NPI:1376617308
Name:STOCKWELL, CHARLES LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEE
Last Name:STOCKWELL
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 1:5109 82ND ST
Mailing Address - Street 2:SUITE 7-214
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-3028
Mailing Address - Country:US
Mailing Address - Phone:281-455-8955
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST # 2A100
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-3530
Practice Address - Country:US
Practice Address - Phone:281-455-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2242TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410030400OtherRAILROAD MEDICARE
TX019517401Medicaid
1182800001OtherDMERC-NSC
00E81NMedicare ID - Type Unspecified
TX019517401Medicaid