Provider Demographics
NPI:1518932730
Name:FLETCHER, CHARLES MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:FLETCHER
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 1:1817 EXECUTIVE SQ
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6086
Mailing Address - Country:US
Mailing Address - Phone:870-930-9200
Mailing Address - Fax:870-930-9120
Practice Address - Street 1:1817 EXECUTIVE SQ
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6086
Practice Address - Country:US
Practice Address - Phone:870-930-9200
Practice Address - Fax:870-930-9120
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2392152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119413722Medicaid
AR119413722Medicaid
AR48346G502Medicare PIN
AR4241850001Medicare NSC