Provider Demographics
NPI:1710917950
Name:ADAMS, CHARLES PULLIAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PULLIAM
Last Name:ADAMS
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 1:1034 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4123
Mailing Address - Country:US
Mailing Address - Phone:904-354-2114
Mailing Address - Fax:904-354-2122
Practice Address - Street 1:1034 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4123
Practice Address - Country:US
Practice Address - Phone:904-354-2114
Practice Address - Fax:904-354-2122
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045165174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15929OtherBCBS
GA00963608AMedicaid
FL041611800Medicaid
FL15929OtherBCBS
GA00963608AMedicaid