Provider Demographics
NPI:1457864837
Name:HEGDALE, CHARLES ALLEN
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALLEN
Last Name:HEGDALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 S BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-2804
Mailing Address - Country:US
Mailing Address - Phone:918-779-7203
Mailing Address - Fax:918-779-7244
Practice Address - Street 1:1214 S BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-2804
Practice Address - Country:US
Practice Address - Phone:918-779-7203
Practice Address - Fax:918-779-7244
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator