Provider Demographics
NPI:1942295282
Name:TITUS, CHARLES DIRK (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DIRK
Last Name:TITUS
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 1:980 AVERITT RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9540
Practice Address - Country:US
Practice Address - Phone:317-881-4143
Practice Address - Fax:317-881-5072
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001973152W00000X
IN18001973A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1973OtherEYEMED VISION CARE
INNAOtherVISION SERVICE PLAN
IN0503450001OtherDURABLE MEDICAL EQUIPMENT
IN5895547OtherAETNA USHC
INNAOtherPRIVATE HEALTHCARE SYSTEM
IN00000091935OtherANTHEM BCBS
IN100193940AMedicaid
IN410032688OtherRAILROAD MEDICARE
INT88595OtherUPIN
IN083940AMedicare PIN