Provider Demographics
NPI:1326063017
Name:MIRABILE, CHARLES PAUL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PAUL
Last Name:MIRABILE
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 1:4140 W MEMORIAL RD
Mailing Address - Street 2:STE 321
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8300
Mailing Address - Country:US
Mailing Address - Phone:405-748-4726
Mailing Address - Fax:405-607-8497
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:STE 321
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-748-4726
Practice Address - Fax:405-607-8497
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20629207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100821300AMedicaid