Provider Demographics
NPI:1366554719
Name:HALL, CHARLES ROLAND (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROLAND
Last Name:HALL
Suffix:
Gender:M
Credentials:DO
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 489
Mailing Address - Street 2:
Mailing Address - City:BANGS
Mailing Address - State:TX
Mailing Address - Zip Code:76823-0489
Mailing Address - Country:US
Mailing Address - Phone:325-752-6521
Mailing Address - Fax:325-752-8101
Practice Address - Street 1:207 HALL ST
Practice Address - Street 2:
Practice Address - City:BANGS
Practice Address - State:TX
Practice Address - Zip Code:76823
Practice Address - Country:US
Practice Address - Phone:325-752-6521
Practice Address - Fax:325-752-8101
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099801502Medicaid
TX120001045OtherRR MEDICARE
TX00QG76Medicare PIN
TX099801502Medicaid