Provider Demographics
NPI:1043516610
Name:PICKETT, CHARLES DELVON (IDMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DELVON
Last Name:PICKETT
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16240 W PIMA ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7927
Mailing Address - Country:US
Mailing Address - Phone:480-233-5021
Mailing Address - Fax:
Practice Address - Street 1:7019 N LITCHFIELD AVE
Practice Address - Street 2:LUKE AFB, 56/AMDS
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309
Practice Address - Country:US
Practice Address - Phone:623-856-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians