Provider Demographics
NPI:1063419778
Name:MCGONAGILL, CHARLES P
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:MCGONAGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 N PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-1002
Mailing Address - Country:US
Mailing Address - Phone:903-569-5432
Mailing Address - Fax:903-569-2994
Practice Address - Street 1:1238 N PACIFIC ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1002
Practice Address - Country:US
Practice Address - Phone:903-569-5432
Practice Address - Fax:903-569-2994
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1785TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23299OtherWEB-TPA
TX00E23AOtherVISION SERVICE PLAN
TX164523601Medicaid
TX22703OtherALWAYS VISION
TX00E23AOtherBENEFIT PLANNERS
TX00E23AOtherPHCS
TX00E23AOtherUNITED HEALTH CARE
TX22703OtherNATIONAL VISION ADMINISTRATORS
TX81257QOtherBLUE CROSS BLUE SHIELD
TX81257QOtherBLUE CROSS BLUE SHIELD GOVERNMENT
TX2388239OtherTEXAS TRUE CHOICE
TX5451470001OtherCIGNA GOVERNMENT SERVICES
TX60583OtherSAFEGUARD
TX00E23AOtherGROUP & PENSION ADMINISTRATORS
TX00E23AOtherHEALTHFIRST TPA
TX5571379OtherAETNA
TX5571379OtherAETNA TRS CARE
TX00E23AOtherPRINCIPAL FINANCIAL GROUP
TX0E23AOtherSUPERIOR
TX00E23AOtherVISION CARE PLAN
TX9933256OtherCIGNA
TXP00249458Medicare PIN
TX22703OtherNATIONAL VISION ADMINISTRATORS
TX8D2376Medicare PIN