Provider Demographics
NPI:1407089436
Name:CHARLEMAGNE, MISTIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:MISTIE
Middle Name:A
Last Name:CHARLEMAGNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MISTIE
Other - Middle Name:A
Other - Last Name:MUTOMBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-936-2038
Practice Address - Street 1:4800 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-936-2038
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD205733207R00000X
ARE-11036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine