Healthcare Provider Details

I. General information

NPI: 1245235266
Provider Name (Legal Business Name): CHARLES TED METTETAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 05/06/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAIN ST
GUN BARREL CITY TX
75156-5312
US

IV. Provider business mailing address

PO BOX 1610
ATHENS TX
75751-9004
US

V. Phone/Fax

Practice location:
  • Phone: 903-887-1011
  • Fax: 903-603-9441
Mailing address:
  • Phone: 903-603-7067
  • Fax: 903-603-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF6042
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC4956
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: