Provider Demographics
NPI:1265067276
Name:SMITH, CHARLES DREW
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DREW
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 RSCR 3345
Mailing Address - Street 2:
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440-4810
Mailing Address - Country:US
Mailing Address - Phone:817-343-9381
Mailing Address - Fax:
Practice Address - Street 1:914 RSCR 3345
Practice Address - Street 2:
Practice Address - City:EMORY
Practice Address - State:TX
Practice Address - Zip Code:75440-4810
Practice Address - Country:US
Practice Address - Phone:817-343-9381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0600X
TX246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic