Provider Demographics
NPI:1740471804
Name:TUBBS, CHARLES GORDON (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GORDON
Last Name:TUBBS
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 1:1426 TADMORE RD
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-3769
Mailing Address - Country:US
Mailing Address - Phone:214-802-0518
Mailing Address - Fax:
Practice Address - Street 1:1426 TADMORE RD
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78133-3769
Practice Address - Country:US
Practice Address - Phone:214-802-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD7343OtherSTATE LICENSE
AT4462569OtherDEA