Provider Demographics
NPI:1497766158
Name:RICHARD, CHARLES HARRY (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HARRY
Last Name:RICHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 NE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1036
Mailing Address - Country:US
Mailing Address - Phone:954-467-8855
Mailing Address - Fax:954-467-8857
Practice Address - Street 1:1528 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1036
Practice Address - Country:US
Practice Address - Phone:954-467-8855
Practice Address - Fax:954-467-8857
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268453500Medicaid
I03791Medicare UPIN