Provider Demographics
NPI:1093701849
Name:COFFEY, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:COFFEY
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 1:12100 COUNTY LINE RD STE A2
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-2006
Mailing Address - Country:US
Mailing Address - Phone:256-325-6722
Mailing Address - Fax:
Practice Address - Street 1:12205 COUNTY LINE RD STE B
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-7720
Practice Address - Country:US
Practice Address - Phone:256-325-6722
Practice Address - Fax:256-325-6724
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000018203Medicaid
AL000018203Medicaid
AL000018203Medicare ID - Type Unspecified