Provider Demographics
NPI:1346421914
Name:GIVENS, CHARLES EDWARD JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:GIVENS
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 MARVIN SHIELDS BLVD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-9007
Mailing Address - Country:US
Mailing Address - Phone:228-871-2810
Mailing Address - Fax:
Practice Address - Street 1:5501 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9007
Practice Address - Country:US
Practice Address - Phone:228-871-2810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman