Provider Demographics
NPI:1548208366
Name:CHARLES, MARVIN B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:B
Last Name:CHARLES
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:P.O. BOX 1074
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3101
Mailing Address - Country:US
Mailing Address - Phone:660-747-5558
Mailing Address - Fax:660-429-4169
Practice Address - Street 1:510 FOSTER LANE
Practice Address - Street 2:SUITE 201
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3101
Practice Address - Country:US
Practice Address - Phone:660-747-5558
Practice Address - Fax:660-429-4169
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006033941208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1548208366Medicaid
MO227883OtherHEALTHCARE USA