Provider Demographics
NPI:1457342727
Name:MYRICK, CHARLEY T III (D O)
Entity Type:Individual
Prefix:DR
First Name:CHARLEY
Middle Name:T
Last Name:MYRICK
Suffix:III
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 CRYSTAL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6875
Mailing Address - Country:US
Mailing Address - Phone:863-688-2334
Mailing Address - Fax:863-577-0299
Practice Address - Street 1:2125 CRYSTAL GROVE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6875
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:863-577-0299
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS89352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71825OtherBCBS
FL266992700Medicaid
FLU0825ZMedicare PIN
FLH86406Medicare UPIN