1962465641 NPI number — MRS. LISA-GAIL THOMAS CHARLES MD

Table of content: MRS. LISA-GAIL THOMAS CHARLES MD (NPI 1962465641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962465641 NPI number — MRS. LISA-GAIL THOMAS CHARLES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLES
Provider First Name:
LISA-GAIL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMAS
Provider Other First Name:
LISA-GAIL
Provider Other Middle Name:
SIMONE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962465641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3083 SW 141ST TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33330-4678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-423-5455
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 CLEVELAND CLINIC BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33331-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-659-5883
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  057853 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 117206 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 131685 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 022074300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".