Provider Demographics
NPI:1619065679
Name:LEWIS, CHARLIE (ABO NCLE)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:ABO NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 23RD ST
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-1905
Mailing Address - Country:US
Mailing Address - Phone:409-762-2433
Mailing Address - Fax:409-762-2438
Practice Address - Street 1:509 23RD ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-1905
Practice Address - Country:US
Practice Address - Phone:409-762-2433
Practice Address - Fax:409-762-2438
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37033156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOP1720OtherEYEMEDVISIONCARE
TX918041Medicaid
TXPCOPTICS@AOL.COMOtherCOMPBENEFITS
TXPO11598OtherSPECTERA