Provider Demographics
NPI:1437104585
Name:PAGE, CHARLES WADE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WADE
Last Name:PAGE
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 1:1303 RAGUET ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4249
Mailing Address - Country:US
Mailing Address - Phone:936-568-9600
Mailing Address - Fax:936-568-9621
Practice Address - Street 1:1303 RAGUET ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4249
Practice Address - Country:US
Practice Address - Phone:936-568-9600
Practice Address - Fax:936-568-9621
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7468174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752893551OtherTAX ID NUMBER
TX752893551OtherTAX ID NUMBER