Provider Demographics
NPI:1801856414
Name:BACKUS, CHARLES L (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:BACKUS
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 1:2514 WESLEY ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1764
Mailing Address - Country:US
Mailing Address - Phone:423-833-5547
Mailing Address - Fax:423-232-0238
Practice Address - Street 1:273 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:BULLS GAP
Practice Address - State:TN
Practice Address - Zip Code:37711-3433
Practice Address - Country:US
Practice Address - Phone:423-393-4146
Practice Address - Fax:423-393-4377
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN15512083A0300X
TNDO1551207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3300057Medicaid
TN3300057Medicare PIN
VAV V3689AMedicare PIN
TN3300057Medicaid
TNP00197221Medicare PIN