Provider Demographics
NPI:1558348979
Name:MALLETT, CHARLES BAKER III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BAKER
Last Name:MALLETT
Suffix:III
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 1:4007 JAMES CASEY STREET
Mailing Address - Street 2:SUITE A200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3361
Mailing Address - Country:US
Mailing Address - Phone:512-441-4400
Mailing Address - Fax:512-441-7421
Practice Address - Street 1:4007 JAMES CASEY STREET
Practice Address - Street 2:SUITE A200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-3361
Practice Address - Country:US
Practice Address - Phone:512-441-4400
Practice Address - Fax:512-441-7421
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111529701Medicaid
B24593Medicare UPIN
00PJ76Medicare ID - Type Unspecified