Provider Demographics
NPI:1932186152
Name:PHELPS, CHARLES R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:PHELPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-4040
Mailing Address - Fax:
Practice Address - Street 1:5016 S US HWY 75
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4584
Practice Address - Country:US
Practice Address - Phone:903-892-1131
Practice Address - Fax:903-327-8023
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7884174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104802702Medicaid
TX85R340Medicare ID - Type Unspecified
TX104802702Medicaid