Provider Demographics
NPI:1831206671
Name:MUTCH, CHARLES ROBERT (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:MUTCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-478-2101
Mailing Address - Fax:918-478-6008
Practice Address - Street 1:104 LONE OAK CIRCLE
Practice Address - Street 2:
Practice Address - City:FT. GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434
Practice Address - Country:US
Practice Address - Phone:918-478-2101
Practice Address - Fax:918-478-6008
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39207Q00000X, 2083X0100X, 247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100015570AMedicaid
OK100015570AMedicaid
OKOK404522Medicare PIN
OK248507803Medicare ID - Type Unspecified