Provider Demographics
NPI:1598833303
Name:EARLE, CHARMAINE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:ELIZABETH
Last Name:EARLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 HESPERIA ROAD
Mailing Address - Street 2:STE 200
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-243-4009
Mailing Address - Fax:760-243-3255
Practice Address - Street 1:12984 HESPERIA RD STE 101
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5819
Practice Address - Country:US
Practice Address - Phone:760-243-4009
Practice Address - Fax:760-243-3255
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A800860OtherBLUE SHIELD
CA00A800861Medicare ID - Type Unspecified
CA00A800860OtherBLUE SHIELD