Provider Demographics
NPI:1477864585
Name:PROBST, CHARLES ERICKSON (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ERICKSON
Last Name:PROBST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-649-2775
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:2313 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1805
Practice Address - Country:US
Practice Address - Phone:601-649-2775
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO1073207Q00000X
MS20941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07689072Medicaid
MS302I083529Medicare Oscar/Certification