Provider Demographics
NPI:1104846625
Name:DODGEN, CHARLES WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WAYNE
Last Name:DODGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:107 JACKSON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3433
Mailing Address - Country:US
Mailing Address - Phone:706-647-8101
Mailing Address - Fax:706-647-8543
Practice Address - Street 1:107 JACKSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3433
Practice Address - Country:US
Practice Address - Phone:706-647-8101
Practice Address - Fax:706-647-8543
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA17100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000116355BMedicaid
GA000116355BMedicaid
GA257754994BMedicare ID - Type Unspecified