Individual
DR. CHARLES B IDOM JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D., FACS
Contact information
Practice address
1434 BROADRICK DR, DALTON, GA 30720-3009
(706) 278-5961
(706) 275-0280
Mailing address
1434 BROADRICK DR, DALTON, GA 30720-3009
(706) 278-5961
(706) 275-0280
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
050482
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00931312A
—
GA
01
—
340019475
RAILROAD MEDICARE
GA
Enumeration date
06/24/2005
Last updated
09/11/2017
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