1548289010 NPI number — DR. CHARLES EDWIN MCMASTERS OPTOMETRIST

Table of content: DR. CHARLES EDWIN MCMASTERS OPTOMETRIST (NPI 1548289010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548289010 NPI number — DR. CHARLES EDWIN MCMASTERS OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMASTERS
Provider First Name:
CHARLES
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OPTOMETRIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548289010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 PROMENADE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-8017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-992-1010
Provider Business Mailing Address Fax Number:
601-992-7700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 PROMENADE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-8017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-992-1010
Provider Business Practice Location Address Fax Number:
601-992-7700
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  530 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 997 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 3504 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08277878 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410048020 . This is a "RR MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 5539 . This is a "DAVIS VISION" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 640935907A . This is a "NISSAN, BCBS OF TENN." identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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