Provider Demographics
NPI:1356433791
Name:DEAN, CHARLIE W (MD)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:W
Last Name:DEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-2394
Mailing Address - Country:US
Mailing Address - Phone:478-333-2100
Mailing Address - Fax:478-333-5201
Practice Address - Street 1:107 WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2394
Practice Address - Country:US
Practice Address - Phone:478-333-2100
Practice Address - Fax:478-333-5201
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABD1222570OtherDEA
GAD45201Medicare UPIN