Healthcare Provider Details

I. General information

NPI: 1316943210
Provider Name (Legal Business Name): CHARLES B IDOM JR. M.D., FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

1434 BROADRICK DR
DALTON GA
30720-3009
US

IV. Provider business mailing address

1434 BROADRICK DR
DALTON GA
30720-3009
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-5961
  • Fax: 706-275-0280
Mailing address:
  • Phone: 706-278-5961
  • Fax: 706-275-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number050482
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: