Provider Demographics
NPI:1629109772
Name:MAESTAS, CHARLES JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JAMES
Last Name:MAESTAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5 PETROGLYPH CIR STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-1001
Mailing Address - Country:US
Mailing Address - Phone:505-455-2842
Mailing Address - Fax:505-455-2941
Practice Address - Street 1:5 PETROGYPH CIRCLE
Practice Address - Street 2:STE. B
Practice Address - City:POJOAQUE
Practice Address - State:NM
Practice Address - Zip Code:87506-0810
Practice Address - Country:US
Practice Address - Phone:505-455-2842
Practice Address - Fax:505-455-2941
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM88-216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07930Medicaid
NM07930Medicaid