Provider Demographics
NPI:1154316008
Name:NAUSE, CHARLES LAMAR JR (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAMAR
Last Name:NAUSE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E MARKET ST
Mailing Address - Street 2:PO BOX 1380
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-4430
Mailing Address - Country:US
Mailing Address - Phone:662-453-5460
Mailing Address - Fax:662-453-5551
Practice Address - Street 1:110 E MARKET ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4430
Practice Address - Country:US
Practice Address - Phone:662-453-5460
Practice Address - Fax:662-453-5551
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016402Medicaid
MS00016402Medicaid
B66137Medicare UPIN