Provider Demographics
NPI:1316930407
Name:HAEGELE, CHARLES WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:HAEGELE
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 1:9870 GATEWAY BLVD N
Mailing Address - Street 2:SUITE B-4
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-4414
Mailing Address - Country:US
Mailing Address - Phone:915-751-0264
Mailing Address - Fax:915-751-2736
Practice Address - Street 1:9870 GATEWAY BLVD N
Practice Address - Street 2:SUITE B-4
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4414
Practice Address - Country:US
Practice Address - Phone:915-751-0264
Practice Address - Fax:915-751-2736
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2570TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127228805Medicaid
TX127228804Medicaid
TX0459530001Medicare NSC
TX127228805Medicaid
T13612Medicare UPIN