Healthcare Provider Details

I. General information

NPI: 1033102629
Provider Name (Legal Business Name): CHARLES WINTERS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 10/17/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 E OLD HICKORY BLVD
MADISON TN
37115-4160
US

IV. Provider business mailing address

1037 E OLD HICKORY BLVD
MADISON TN
37115-4160
US

V. Phone/Fax

Practice location:
  • Phone: 615-860-0228
  • Fax: 615-865-2799
Mailing address:
  • Phone: 615-860-0228
  • Fax: 615-865-2799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD16862
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: