Provider Demographics
NPI:1962495341
Name:RHODUS, CHARLES DALE (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DALE
Last Name:RHODUS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 NEW COPELAND RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-6217
Mailing Address - Country:US
Mailing Address - Phone:903-592-7200
Mailing Address - Fax:903-592-7211
Practice Address - Street 1:5826 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6217
Practice Address - Country:US
Practice Address - Phone:903-592-7200
Practice Address - Fax:903-592-7211
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1375213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161772848OtherCOMMERCIAL
TX8X2110OtherBCBS PIN
TXP00383164OtherMEDICARE RAILROAD
TX046291302Medicaid
TXP00383164OtherMEDICARE RAILROAD
TX8F4921Medicare PIN