Provider Demographics
NPI:1063451672
Name:FORD, CHARLES DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVIS
Last Name:FORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636019
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 RB WILSON DR
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-1727
Practice Address - Country:US
Practice Address - Phone:731-986-4461
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38666207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4110535OtherBCBS
TNP00255517OtherRAILROAD MEDICARE
TN3898586Medicaid
TN3898586Medicaid
TN4110535OtherBCBS