Healthcare Provider Details

I. General information

NPI: 1053309997
Provider Name (Legal Business Name): CHARLES VON ODEN HUGHES III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116A JOHN DUPRE DR
LEVELLAND TX
79336
US

IV. Provider business mailing address

116A JOHN DUPRE DR
LEVELLAND TX
79336
US

V. Phone/Fax

Practice location:
  • Phone: 806-894-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG2997
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: