Provider Demographics
NPI:1598855827
Name:BROCKWELL, CHARLES PHILLIP (M D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PHILLIP
Last Name:BROCKWELL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 DEL CARMEN DR
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-7614
Mailing Address - Country:US
Mailing Address - Phone:256-237-2935
Mailing Address - Fax:
Practice Address - Street 1:2109 DEL CARMEN DR
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-7614
Practice Address - Country:US
Practice Address - Phone:256-237-2935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist