Provider Demographics
NPI:1366521205
Name:LODGE, CHARLES GARY (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GARY
Last Name:LODGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3037
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3037
Mailing Address - Country:US
Mailing Address - Phone:229-985-3320
Mailing Address - Fax:229-890-1282
Practice Address - Street 1:6 HOSPITAL PARK
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6700
Practice Address - Country:US
Practice Address - Phone:229-985-3320
Practice Address - Fax:229-890-1282
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA024019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00296942BMedicaid
GAD30082Medicare UPIN
GA00296942BMedicaid