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General NPI Number Information
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NPI Number | 1245235266
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Entity Type | Individual
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Provider Name | CHARLES TED METTETAL M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/16/2005
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Last Update Date | 05/06/2024
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Provider Practice Location Address
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Address Line | 801 W MAIN ST
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City | GUN BARREL CITY
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State | TX
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Zip | 75156-5312
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Country | US
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Telephone | 903-887-1011
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Fax | 903-603-9441
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Provider Business Mailing Address
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Address Line | PO BOX 1610
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City | ATHENS
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State | TX
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Zip | 75751-9004
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Country | US
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Telephone | 903-603-7067
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Fax | 903-603-7595
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | F6042
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | C4956
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License Number State | AR
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