Provider Demographics
NPI:1629141411
Name:RILEY, CHARLES P (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:P
Last Name:RILEY
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 1:8333 N DAVIS HWY FL 4
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6050
Mailing Address - Country:US
Mailing Address - Phone:850-969-7979
Mailing Address - Fax:850-969-1839
Practice Address - Street 1:8333 N DAVIS HWY FL 4
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6050
Practice Address - Country:US
Practice Address - Phone:850-969-7979
Practice Address - Fax:850-969-1839
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17257174400000X
FLME19379207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist