1326095381 NPI number — CHARLES C CARTER MD DPH PLLC

Table of content: (NPI 1326095381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326095381 NPI number — CHARLES C CARTER MD DPH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES C CARTER MD DPH PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326095381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 575
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTUS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73522-0575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-480-1600
Provider Business Mailing Address Fax Number:
580-480-1601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 E BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
ALTUS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-480-1600
Provider Business Practice Location Address Fax Number:
580-480-1601
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
580-480-1600

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  19154 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100116810E , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200113300A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 445440041004 . This is a "BCBS BILLING #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 19154 . This is a "OK STATE LICENSE #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100116810D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37D1053611 . This is a "CLIA WAIVED" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: C-8500 . This is a "ARKANSAS STATE LICENSE #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 203705843 . This is a "TRICARE/HUMANA PROVIDER #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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