Basic Information
| Provider Information | |||||||||
| NPI: | 1942295282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TITUS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DIRK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 AVERITT RD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461439540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178814143 | ||||||||
| FaxNumber: | 3178815072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001973 | IN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 18001973A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | IN1973 | 01 | IN | EYEMED VISION CARE | OTHER | NA | 01 | IN | VISION SERVICE PLAN | OTHER | 0503450001 | 01 | IN | DURABLE MEDICAL EQUIPMENT | OTHER | 5895547 | 01 | IN | AETNA USHC | OTHER | NA | 01 | IN | PRIVATE HEALTHCARE SYSTEM | OTHER | 00000091935 | 01 | IN | ANTHEM BCBS | OTHER | 100193940A | 05 | IN | MEDICAID | 410032688 | 01 | IN | RAILROAD MEDICARE | OTHER | T88595 | 01 | IN | UPIN | OTHER |