Provider Demographics
NPI:1518925825
Name:HUDDLESTON, CHARLES I (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:I
Last Name:HUDDLESTON
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 1:200 FORT SANDERS WEST BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3357
Mailing Address - Country:US
Mailing Address - Phone:865-342-5811
Mailing Address - Fax:865-342-5857
Practice Address - Street 1:200 FORT SANDERS WEST BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3357
Practice Address - Country:US
Practice Address - Phone:865-342-5811
Practice Address - Fax:865-342-5857
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5764207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2005934OtherBLUE CROSS
TN4034632OtherAETNA
TN3376258Medicaid
TN3154921Medicare ID - Type Unspecified
TN3376258Medicaid