1821139080 NPI number — DR. CHARLES ALLEN CALLAWAY R.PH, O.D.

Table of content: DR. CHARLES ALLEN CALLAWAY R.PH, O.D. (NPI 1821139080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821139080 NPI number — DR. CHARLES ALLEN CALLAWAY R.PH, O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAWAY
Provider First Name:
CHARLES
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
R.PH, O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821139080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2120 HIGHWAY 76 STE A
Provider Second Line Business Mailing Address:
COHUTTA PLACE PLAZA
Provider Business Mailing Address City Name:
CHATSWORTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30705-7302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-695-0107
Provider Business Mailing Address Fax Number:
706-517-9633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 HIGHWAY 76 STE A
Provider Second Line Business Practice Location Address:
COHUTTA PLACE
Provider Business Practice Location Address City Name:
CHATSWORTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30705-7302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-695-0107
Provider Business Practice Location Address Fax Number:
706-517-9633
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001074 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: RPH012110 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1689833089 . This is a "MEDICARE GROUP NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000667664A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511G700552 . This is a "MEDICARE PROVIDER PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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