Provider Demographics
NPI:1366646150
Name:CRIDDLE, CHARLES TRAVIS (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TRAVIS
Last Name:CRIDDLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:217 W GEORGIA AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6811
Mailing Address - Country:US
Mailing Address - Phone:208-463-3234
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:3277 E LOUISE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9351
Practice Address - Country:US
Practice Address - Phone:208-468-5930
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125-051457208000000X
IDO-0532208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8084089Medicaid