Provider Demographics
NPI:1205828258
Name:MOK, CHARLES JR (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MOK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1573 N CLINE AVE
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-1567
Mailing Address - Country:US
Mailing Address - Phone:219-838-2312
Mailing Address - Fax:219-972-7177
Practice Address - Street 1:1573 N CLINE AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1567
Practice Address - Country:US
Practice Address - Phone:219-838-2312
Practice Address - Fax:219-972-7177
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02002327A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN140230QQQMedicare ID - Type Unspecified
H41600Medicare UPIN