Provider Demographics
NPI:1316943210
Name:IDOM, CHARLES B JR (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:IDOM
Suffix:JR
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3009
Mailing Address - Country:US
Mailing Address - Phone:706-278-5961
Mailing Address - Fax:706-275-0280
Practice Address - Street 1:1434 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3009
Practice Address - Country:US
Practice Address - Phone:706-278-5961
Practice Address - Fax:706-275-0280
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2017-09-11
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
GA050482208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340019475OtherRAILROAD MEDICARE
GA00931312AMedicaid
GA00931312AMedicaid
GA340019475OtherRAILROAD MEDICARE
GAH15460Medicare UPIN