Provider Demographics
NPI:1245238823
Name:PROPST, CHARLIE WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:WAYNE
Last Name:PROPST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:
Other - Last Name:PROPST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2021 HOLLY LEAF DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0923
Mailing Address - Country:US
Mailing Address - Phone:903-939-8395
Mailing Address - Fax:903-939-8612
Practice Address - Street 1:1100 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3301
Practice Address - Country:US
Practice Address - Phone:903-526-5660
Practice Address - Fax:903-526-5644
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0024GUOtherBLUE CROSS
TX88Y133OtherBLUE CROSS
TX0024GUOtherBLUE CROSS
TX88Y133Medicare PIN
TX88Y133OtherBLUE CROSS