Provider Demographics
NPI:1649575291
Name:CHARLES L. HEATON, MD, PA
Entity type:Organization
Organization Name:CHARLES L. HEATON, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES-ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-526-0444
Mailing Address - Street 1:3415 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8355
Mailing Address - Country:US
Mailing Address - Phone:903-526-0444
Mailing Address - Fax:903-526-2051
Practice Address - Street 1:1205 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5539
Practice Address - Country:US
Practice Address - Phone:903-234-0771
Practice Address - Fax:903-234-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty