Provider Demographics
NPI:1558354696
Name:CONNOR, CHARLES G (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:CONNOR
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 1:9725 DATAPOINT DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2384
Mailing Address - Country:US
Mailing Address - Phone:210-283-6824
Mailing Address - Fax:210-283-6890
Practice Address - Street 1:9725 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2384
Practice Address - Country:US
Practice Address - Phone:210-283-6824
Practice Address - Fax:210-283-6890
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1238152W00000X
TX7934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1238OtherOD
TN3597523Medicaid
TN3597524Medicare ID - Type Unspecified
TN1238OtherOD
TN0416100001Medicare NSC
TN3597523Medicaid