Provider Demographics
NPI:1366429854
Name:PICKETT, CHARLTON JUDSON (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLTON
Middle Name:JUDSON
Last Name:PICKETT
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 PENDLETON ROAD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4837
Mailing Address - Country:US
Mailing Address - Phone:706-738-9834
Mailing Address - Fax:706-736-4111
Practice Address - Street 1:1417 PENDLETON ROAD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4837
Practice Address - Country:US
Practice Address - Phone:706-738-9824
Practice Address - Fax:706-736-4111
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00377979BMedicaid
SC140437Medicaid
GAD42066Medicare UPIN
GA080105800Medicare ID - Type UnspecifiedRAILROAD
SC140437Medicaid