Provider Demographics
NPI:1639170715
Name:BRISENO, CHARLES GEORGE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GEORGE
Last Name:BRISENO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9100
Mailing Address - Fax:239-343-9108
Practice Address - Street 1:9131 COLLEGE POINTE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-432-0101
Practice Address - Fax:239-432-9659
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME80345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260152400Medicaid
FL51700ZMedicare PIN
FL110217096Medicare PIN