Provider Demographics
NPI:1942294905
Name:HEACOCK, CHARLES E (OD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:E
Last Name:HEACOCK
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:840 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3256
Practice Address - Country:US
Practice Address - Phone:386-734-1766
Practice Address - Fax:386-740-7866
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078734500Medicaid
19113ZMedicare PIN
FL191132Medicare ID - Type Unspecified
T65093Medicare UPIN
FL078734500Medicaid