Provider Demographics
NPI:1225026875
Name:MABRY, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:MABRY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:870-541-7211
Mailing Address - Fax:870-541-4297
Practice Address - Street 1:1609 W 40TH AVE STE 403
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6365
Practice Address - Country:US
Practice Address - Phone:870-535-8280
Practice Address - Fax:870-535-5458
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2023-10-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARC4953208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104825001Medicaid
AR532487584Medicare PIN
AR104825001Medicaid