Provider Demographics
NPI:1376583526
Name:TATE, CHARLES W III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:TATE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-251-2500
Mailing Address - Fax:435-656-4907
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:STE 1500
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-251-2500
Practice Address - Fax:435-656-4907
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42885174400000X, 207RC0001X, 207RC0000X
UT7724231-1205207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85581224Medicaid
CO85581224Medicaid
UTU000075626Medicare PIN