Provider Demographics
NPI:1275882953
Name:CHARLES LOVELACE DO PA
Entity Type:Organization
Organization Name:CHARLES LOVELACE DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-342-6265
Mailing Address - Street 1:1320 N GALLOWAY AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2440
Mailing Address - Country:US
Mailing Address - Phone:972-342-6265
Mailing Address - Fax:972-437-0042
Practice Address - Street 1:1320 N GALLOWAY AVE STE 103
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2440
Practice Address - Country:US
Practice Address - Phone:972-342-6265
Practice Address - Fax:972-437-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2019-12-05
Deactivation Date:2019-11-21
Deactivation Code:
Reactivation Date:2019-12-05
Provider Licenses
StateLicense IDTaxonomies
TXG9871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1982771432OtherG9871 LIC