Provider Demographics
NPI:1962485359
Name:ORR, CHARLES RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:ORR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1492 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3860
Mailing Address - Country:US
Mailing Address - Phone:931-648-0544
Mailing Address - Fax:931-648-3625
Practice Address - Street 1:1492 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3860
Practice Address - Country:US
Practice Address - Phone:931-648-0544
Practice Address - Fax:931-648-3625
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599631Medicaid
TN3599631Medicaid
3593463Medicare PIN