Provider Demographics
NPI:1740395623
Name:COLE, CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-377-5652
Mailing Address - Fax:888-241-1404
Practice Address - Street 1:2801 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2544
Practice Address - Country:US
Practice Address - Phone:979-776-5967
Practice Address - Fax:979-774-4849
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO42220207Q00000X
TXN3570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95109773Medicaid
TX8V4248OtherTX BCBS
TX208601901Medicaid
TX208601901Medicaid
TX8V4248OtherTX BCBS
CO95109773Medicaid