Provider Demographics
NPI:1003919994
Name:GREESON, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:GREESON
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:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-481-2166
Practice Address - Street 1:120 E BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5919
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:325-481-2166
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1758207N00000X, 207N00000X
OK22496207NS0135X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FB828OtherBCBS
TX315032802Medicaid
TX272240YKXYMedicare PIN
TXP01246320Medicare PIN
TX272240YKXVMedicare PIN