MEDICARE: DR. CHARLES TED METTETAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	F6042	TX
2	207Q00000X	Family Medicine Physician	C4956	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	80F795	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1245235266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES TED METTETAL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1610
Second Line	:
City	:	ATHENS
State	:	TX
Zip	:	75751-9004
Country	:	US
Telephone Number	:	903-603-7067
Fax Number	:	903-603-7595

Provider Business Practice Location Address
First Line	:	801 W MAIN ST
Second Line	:
City	:	GUN BARREL CITY
State	:	TX
Zip	:	75156-5312
Country	:	US
Telephone Number	:	903-887-1011
Fax Number	:	903-603-9441

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	05/06/2024

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