Provider Demographics
NPI:1356393714
Name:MATTHEWS, CHARLES ODELL (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ODELL
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12909 N 56TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-1274
Mailing Address - Country:US
Mailing Address - Phone:813-985-0900
Mailing Address - Fax:
Practice Address - Street 1:12909 N 56TH ST STE 203
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-1274
Practice Address - Country:US
Practice Address - Phone:813-985-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6713103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75019OtherBLUECROSS BLUESHIELD# -FL
FL75019OtherBLUECROSS BLUESHIELD# -FL