Provider Demographics
NPI:1366441156
Name:GARRISON, CHARLES O (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:O
Last Name:GARRISON
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 1:1125 W ALAMEDA RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6143
Mailing Address - Country:US
Mailing Address - Phone:208-237-1151
Mailing Address - Fax:208-237-9721
Practice Address - Street 1:1125 W ALAMEDA RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6143
Practice Address - Country:US
Practice Address - Phone:208-237-1151
Practice Address - Fax:208-237-9721
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3488207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1138514Medicare ID - Type Unspecified
IDE95384Medicare UPIN