Provider Demographics
NPI:1760467443
Name:COX, CHARLES G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:COX
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 1:17500 WHIPPOORWILL TRL
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-9735
Mailing Address - Country:US
Mailing Address - Phone:510-703-3326
Mailing Address - Fax:
Practice Address - Street 1:500 1ST AVE
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-9406
Practice Address - Country:US
Practice Address - Phone:530-832-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40851207RG0100X
TXR0379207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology