Individual
DR. CHARLES B IDOM JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D., FACS
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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