Provider Demographics
NPI:1083669204
Name:MORRISON, CHARLES REESE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:REESE
Last Name:MORRISON
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-491-6482
Mailing Address - Fax:
Practice Address - Street 1:1665 BONANZA DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-5127
Practice Address - Country:US
Practice Address - Phone:435-649-7640
Practice Address - Fax:435-649-1365
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5525050-1205173000000X
UT5523050-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5365Medicaid
UTD5365Medicaid