Provider Demographics
NPI:1164404893
Name:TRIBBETT, CHARLES R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:TRIBBETT
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 1:301 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-2211
Mailing Address - Country:US
Mailing Address - Phone:574-240-1111
Mailing Address - Fax:574-240-1113
Practice Address - Street 1:301 W HARRISON STREET
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-0000
Practice Address - Country:US
Practice Address - Phone:574-240-1111
Practice Address - Fax:574-240-1113
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036854A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201351020AMedicaid
INE39369OtherMEDICARE
IN921430AMedicare ID - Type Unspecified