Provider Demographics
NPI:1033179270
Name:SIDLOW, CHARLES JEFFREY (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JEFFREY
Last Name:SIDLOW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:958 JOE FRANK HARRIS PKWY SE BLDG A
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2175
Mailing Address - Country:US
Mailing Address - Phone:770-386-1389
Mailing Address - Fax:770-386-4894
Practice Address - Street 1:958 JOE FRANK HARRIS PKWY SE BLDG A
Practice Address - Street 2:SUITE 106
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2175
Practice Address - Country:US
Practice Address - Phone:770-386-1389
Practice Address - Fax:770-386-4894
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000560213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000333803AMedicaid
GA1588842686Medicare NSC
GA000333803AMedicaid