Provider Demographics
NPI:1346202405
Name:CRIST, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:CRIST
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 1:5495 EAST STATE ROUTE Y
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65010
Mailing Address - Country:US
Mailing Address - Phone:573-657-1107
Mailing Address - Fax:573-657-1110
Practice Address - Street 1:5495 E ROUTE Y
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MO
Practice Address - Zip Code:65010-9871
Practice Address - Country:US
Practice Address - Phone:573-657-1107
Practice Address - Fax:573-657-1110
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2D89207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000007409Medicare ID - Type Unspecified
A13235Medicare UPIN