Provider Demographics
NPI:1174531735
Name:CADENHEAD, CHARLES W (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:CADENHEAD
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 1:1417 NORTH 1ST STREET SUITE A
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:TX
Mailing Address - Zip Code:79521-0938
Mailing Address - Country:US
Mailing Address - Phone:940-864-2636
Mailing Address - Fax:940-864-3009
Practice Address - Street 1:1417 NORTH 1ST STREET SUITE A
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:TX
Practice Address - Zip Code:79521-0938
Practice Address - Country:US
Practice Address - Phone:940-864-2636
Practice Address - Fax:940-864-3009
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4241207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1225468-01Medicaid
TX063645801Medicaid
TX0049REOtherBLUE CROSS AND BLUE SHIELD
TXB21635Medicare UPIN
TX613086Medicare PIN
TX063645801Medicaid