Provider Demographics
NPI:1801902606
Name:CHILDRESS, CARL W (OD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:W
Last Name:CHILDRESS
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 1:408 MAGRILL STREET
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6444
Mailing Address - Country:US
Mailing Address - Phone:903-753-4436
Mailing Address - Fax:903-757-4400
Practice Address - Street 1:408 E MAGRILL ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6444
Practice Address - Country:US
Practice Address - Phone:903-753-4436
Practice Address - Fax:903-757-4400
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1892152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E14JMedicare PIN
TX505835Medicare ID - Type UnspecifiedGRP #
TXT12634Medicare UPIN