Provider Demographics
NPI:1568501716
Name:NORMAN, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:NORMAN
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 1:125 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3424
Mailing Address - Country:US
Mailing Address - Phone:931-854-9274
Mailing Address - Fax:931-854-9276
Practice Address - Street 1:125 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3424
Practice Address - Country:US
Practice Address - Phone:931-854-9274
Practice Address - Fax:931-854-9276
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0618174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE93185Medicare UPIN
TXE93185Medicare UPIN