Provider Demographics
NPI:1275759367
Name:PAINE, CHARLES STEPHEN JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEPHEN
Last Name:PAINE
Suffix:JR
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 1:8706 W ESECO
Mailing Address - Street 2:
Mailing Address - City:AGRA
Mailing Address - State:OK
Mailing Address - Zip Code:74824-6208
Mailing Address - Country:US
Mailing Address - Phone:918-285-6344
Mailing Address - Fax:
Practice Address - Street 1:3200 S KINGS HWY
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-5355
Practice Address - Country:US
Practice Address - Phone:918-225-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036853207Q00000X
OK28754208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine