Provider Demographics
NPI:1073600847
Name:STEPHENS, CHARLES G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:222 MAIN STREET
Mailing Address - Street 2:PO BOX 127
Mailing Address - City:MINNEOLA
Mailing Address - State:KS
Mailing Address - Zip Code:67865-8511
Mailing Address - Country:US
Mailing Address - Phone:620-885-4202
Mailing Address - Fax:620-885-4805
Practice Address - Street 1:222 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:KS
Practice Address - Zip Code:67865-8511
Practice Address - Country:US
Practice Address - Phone:620-885-4202
Practice Address - Fax:620-885-4805
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-12395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10086090Medicaid
KS10086090Medicaid
B68360Medicare UPIN
055802Medicare ID - Type UnspecifiedMINNEOLA CLINIC