Provider Demographics
NPI:1740282631
Name:MARTIN, CHARLES E (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CENTER PARK DR
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2103
Mailing Address - Country:US
Mailing Address - Phone:865-690-9998
Mailing Address - Fax:865-691-7364
Practice Address - Street 1:111 CENTER PARK DR
Practice Address - Street 2:SUITE 1300
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2103
Practice Address - Country:US
Practice Address - Phone:865-690-9998
Practice Address - Fax:865-691-7364
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000527103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3680546Medicare ID - Type Unspecified