Provider Demographics
NPI:1528553997
Name:PATEL, CHARLOTTE MEDLOCK (DO)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MEDLOCK
Last Name:PATEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:MEDLOCK
Other - Last Name:WERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1690 SKYLYN DR STE 210
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1075
Practice Address - Country:US
Practice Address - Phone:864-253-8170
Practice Address - Fax:864-585-7787
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT018844207Q00000X
SC83760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC837607Medicaid
SCSCL5216084OtherMEDICARE PIN