Provider Demographics
NPI:1568607984
Name:CHARLES, MARISSA G (DO)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:G
Last Name:CHARLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:E
Other - Last Name:GARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6157 NW LOOP 410
Mailing Address - Street 2:STE. 124
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-3302
Mailing Address - Country:US
Mailing Address - Phone:210-523-1411
Mailing Address - Fax:210-523-9307
Practice Address - Street 1:6157 NW LOOP 410
Practice Address - Street 2:STE. 124
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-3302
Practice Address - Country:US
Practice Address - Phone:210-523-1411
Practice Address - Fax:210-523-9307
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX386468YLPSOtherWELLMED MEDICARE
TX1994998-04OtherWELLMED MEDICAID