Provider Demographics
NPI:1609805431
Name:HUDDLESTON, CHARLES T (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
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 1:203 N CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2498
Mailing Address - Country:US
Mailing Address - Phone:931-528-1992
Mailing Address - Fax:931-526-4381
Practice Address - Street 1:203 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-528-1992
Practice Address - Fax:931-526-4381
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN038564207P00000X
VA0101237006207P00000X
TNMD38564208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008191E59Medicare ID - Type Unspecified
VAI10654Medicare UPIN