Provider Demographics
NPI:1245235266
Name:METTETAL, CHARLES TED (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TED
Last Name:METTETAL
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 1610
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1610
Mailing Address - Country:US
Mailing Address - Phone:903-887-1011
Mailing Address - Fax:
Practice Address - Street 1:801 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-5312
Practice Address - Country:US
Practice Address - Phone:903-887-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4956207Q00000X
TXF6042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133097901Medicaid
TX80F795OtherBCBS
TX80F795Medicare ID - Type UnspecifiedMEDICARE NUMBER
TXB24889Medicare UPIN