Provider Demographics
NPI:1326062589
Name:LIVELY, CHARLES AUBORN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:AUBORN
Last Name:LIVELY
Suffix:
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 1:608 N MUSKINGUM AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4539
Mailing Address - Country:US
Mailing Address - Phone:432-580-9168
Mailing Address - Fax:432-335-9217
Practice Address - Street 1:608 N MUSKINGUM AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4539
Practice Address - Country:US
Practice Address - Phone:432-580-9168
Practice Address - Fax:432-580-8221
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6384207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123169804Medicaid
TX00J21BMedicare ID - Type Unspecified20