Provider Demographics
NPI:1487638979
Name:CHARLES E WOMACK MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CHARLES E WOMACK MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-946-3373
Mailing Address - Street 1:5252 N MERIDIAN AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2178
Mailing Address - Country:US
Mailing Address - Phone:405-946-3373
Mailing Address - Fax:405-947-1177
Practice Address - Street 1:5252 N MERIDIAN AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2178
Practice Address - Country:US
Practice Address - Phone:405-946-3373
Practice Address - Fax:405-947-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC95672Medicare UPIN