Provider Demographics
NPI:1073700159
Name:CHARLES M MAPLES
Entity Type:Organization
Organization Name:CHARLES M MAPLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAPLES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:562-430-6850
Mailing Address - Street 1:3771 KATELLA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3108
Mailing Address - Country:US
Mailing Address - Phone:562-430-6850
Mailing Address - Fax:562-280-2882
Practice Address - Street 1:3771 KATELLA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3108
Practice Address - Country:US
Practice Address - Phone:562-430-6850
Practice Address - Fax:562-280-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18597Medicare PIN