Provider Demographics
NPI:1619084571
Name:CHARLES, DEREK B (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:B
Last Name:CHARLES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 CROSSINGS CIR
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8419
Mailing Address - Country:US
Mailing Address - Phone:615-553-5500
Mailing Address - Fax:615-758-3875
Practice Address - Street 1:5002 CROSSINGS CIR
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8419
Practice Address - Country:US
Practice Address - Phone:615-553-5500
Practice Address - Fax:615-758-3875
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7419225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7419OtherLICENSE #