Healthcare Provider Details

I. General information

NPI: 1861487878
Provider Name (Legal Business Name): CHARLES HENRY TADLOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6725 S. EASTERN AVE. #6
LAS VEGAS NV
89119
US

IV. Provider business mailing address

6725 S. EASTERN AVE. #6
LAS VEGAS NV
89119
US

V. Phone/Fax

Practice location:
  • Phone: 702-474-0200
  • Fax: 702-474-7165
Mailing address:
  • Phone: 702-474-0200
  • Fax: 702-474-7165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number8402
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number26067
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG62878
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number5937479-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: