Basic Information
| Provider Information | |||||||||
| NPI: | 1891774188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLODFELTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MANLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2400 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329022400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218373820 | ||||||||
| FaxNumber: | 3218373654 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W COCOA BEACH CSWY | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217997111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME0071159 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 250653000 | 05 | FL | MEDICAID | 32302 | 01 | FL | BCBS | OTHER |