Provider Demographics
NPI:1326095381
Name:CHARLES C CARTER MD DPH PLLC
Entity Type:Organization
Organization Name:CHARLES C CARTER MD DPH PLLC
Other - Org Name:CHARLES C CARTER MD DPH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD DPH
Authorized Official - Phone:580-480-1600
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73522-0575
Mailing Address - Country:US
Mailing Address - Phone:580-480-1600
Mailing Address - Fax:580-480-1601
Practice Address - Street 1:1015 E BROADWAY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521
Practice Address - Country:US
Practice Address - Phone:580-480-1600
Practice Address - Fax:580-480-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19154207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100116810EMedicaid
OK200113300AMedicaid
OK445440041004OtherBCBS BILLING #
OK19154OtherOK STATE LICENSE #
OK100116810DMedicaid
OK37D1053611OtherCLIA WAIVED
ARC-8500OtherARKANSAS STATE LICENSE #
OK203705843OtherTRICARE/HUMANA PROVIDER #
OK445440041004OtherBCBS BILLING #
OK445440041004OtherBCBS BILLING #
OK19154OtherOK STATE LICENSE #
OK37D1053611OtherCLIA WAIVED
OK37D1053611OtherCLIA WAIVED
ARC-8500OtherARKANSAS STATE LICENSE #
OK900522318Medicare ID - Type UnspecifiedGROUP/CLINIC PROVIDER #
OK445-44-0041OtherSOCIAL SECURITY NUMBER
OK20-3705843OtherTIN-EXPIRES 06-30-2007
OK=========001OtherBCBS GROUP #