Provider Demographics
NPI:1164506226
Name:BAMBERGER, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BAMBERGER
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 1:416 SOUTH HENDERSON
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-338-4636
Mailing Address - Fax:817-335-5421
Practice Address - Street 1:416 SOUTH HENDERSON
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1017
Practice Address - Country:US
Practice Address - Phone:817-338-4636
Practice Address - Fax:817-335-5421
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7557208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127666904Medicaid
TX127666904Medicaid
TX0591390001Medicare NSC
TX0098BJMedicare PIN