Provider Demographics
NPI:1497827356
Name:TOLLETT, CHARLES ALBERT JR (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALBERT
Last Name:TOLLETT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:P O BOX 327
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-0327
Mailing Address - Country:US
Mailing Address - Phone:812-683-6339
Mailing Address - Fax:812-683-6337
Practice Address - Street 1:407 E 22ND ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-8964
Practice Address - Country:US
Practice Address - Phone:812-683-6339
Practice Address - Fax:812-683-6337
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01042157208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000238257OtherANTHEM
IN1004142200Medicaid
IN000000238257OtherANTHEM
IN1004142200Medicaid
M400052112Medicare PIN
C95572Medicare UPIN