Provider Demographics
NPI:1376075507
Name:CHARLES, JEAN ELIZZE MABUTE (DO)
Entity Type:Individual
Prefix:
First Name:JEAN ELIZZE
Middle Name:MABUTE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MONTGOMERY ST
Mailing Address - Street 2:FL 6
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2553
Mailing Address - Country:US
Mailing Address - Phone:682-582-2921
Mailing Address - Fax:817-598-4705
Practice Address - Street 1:855 MONTGOMERY ST FL 6
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-7625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT1316207N00000X
TXBP20065105390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program