Healthcare Provider Details

I. General information

NPI: 1962495341
Provider Name (Legal Business Name): CHARLES DALE RHODUS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5826 NEW COPELAND RD
TYLER TX
75703-6217
US

IV. Provider business mailing address

5826 NEW COPELAND RD
TYLER TX
75703-6217
US

V. Phone/Fax

Practice location:
  • Phone: 903-592-7200
  • Fax: 903-592-7211
Mailing address:
  • Phone: 903-592-7200
  • Fax: 903-592-7211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1375
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: