Provider Demographics
NPI:1700405503
Name:MINOR, CHARLES WESLEY
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WESLEY
Last Name:MINOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GOVERNORS DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-5123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2165 HIGHWAY 78 STE 100
Practice Address - Street 2:
Practice Address - City:DORA
Practice Address - State:AL
Practice Address - Zip Code:35062-4539
Practice Address - Country:US
Practice Address - Phone:205-648-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-11
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL43012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine