Provider Demographics
NPI:1053396739
Name:CHARLES, DEBORAH J (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 138
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-0138
Mailing Address - Country:US
Mailing Address - Phone:229-276-3356
Mailing Address - Fax:229-276-3382
Practice Address - Street 1:902 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3234
Practice Address - Country:US
Practice Address - Phone:229-276-3356
Practice Address - Fax:229-276-3382
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0287422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000400562LMedicaid
GAE77987Medicare UPIN
GA000400562LMedicaid