Provider Demographics
NPI:1497765994
Name:CHARLES J. LASTRAPES, D.O., LLC
Entity Type:Organization
Organization Name:CHARLES J. LASTRAPES, D.O., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LASTRAPES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:573-335-8282
Mailing Address - Street 1:937 BROADWAY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5493
Mailing Address - Country:US
Mailing Address - Phone:573-335-8288
Mailing Address - Fax:
Practice Address - Street 1:937 BROADWAY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5493
Practice Address - Country:US
Practice Address - Phone:573-335-8288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO107336OtherBLUE CROSS BLUE SHIELD
MO335767OtherHEALTHLINK
MO283223OtherCMR
MODF0280OtherRAILROAD MEDICARE
MODF0280OtherRAILROAD MEDICARE
MOG00152Medicare UPIN