Provider Demographics
NPI:1053467894
Name:MALISKA, CHARLES MILES III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MILES
Last Name:MALISKA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2402 FRIST BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4838
Mailing Address - Country:US
Mailing Address - Phone:772-462-3939
Mailing Address - Fax:
Practice Address - Street 1:2402 FRIST BLVD STE 204
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4838
Practice Address - Country:US
Practice Address - Phone:772-462-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27745208600000X, 2086S0102X, 2086S0127X
CAA99319208600000X, 2086S0102X, 2086S0127X
TXR2163208600000X, 2086S0102X, 2086S0127X
NY303595208600000X, 2086S0102X, 2086S0127X
FLME1508162086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200330440AMedicaid