Provider Demographics
NPI:1144217803
Name:SMITH, CHARLES GRAY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GRAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:400 W CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:TN
Mailing Address - Zip Code:38574-1166
Mailing Address - Country:US
Mailing Address - Phone:931-839-2224
Mailing Address - Fax:931-839-2368
Practice Address - Street 1:400 W CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:TN
Practice Address - Zip Code:38574
Practice Address - Country:US
Practice Address - Phone:931-839-2224
Practice Address - Fax:931-839-2368
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-28
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN15753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3846287Medicaid
TN3846287Medicaid
A97651Medicare UPIN