Provider Demographics
NPI:1689899676
Name:MATTHEWS, CHARLES HARRISON JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HARRISON
Last Name:MATTHEWS
Suffix:JR
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 1:2800 E HWY 114
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5305
Mailing Address - Country:US
Mailing Address - Phone:817-693-0900
Mailing Address - Fax:713-863-8308
Practice Address - Street 1:2600 SAINT MICHAEL DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2372
Practice Address - Country:US
Practice Address - Phone:903-614-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001964207Q00000X
IN01078263A2085R0001X
TXQ23402085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1I0164OtherMEDICARE
TX348741503Medicaid
TXP02587361OtherRR MEDICARE