Basic Information
| Provider Information | |||||||||
| NPI: | 1366530529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRINIDAD | ||||||||
| FirstName: | CHARLTON | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 TAYLOR RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361177790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1739 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PRATTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360665525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343588106 | ||||||||
| FaxNumber: | 3343588107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207R00000X | 20890 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51510266 | 01 | AL | BCBS | OTHER |