Provider Demographics
NPI:1659314763
Name:LIN, CHARLIE T (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:T
Last Name:LIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:TZUCHANG
Other - Middle Name:
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-688-6300
Mailing Address - Fax:
Practice Address - Street 1:577 S RIVER RD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2097
Practice Address - Country:US
Practice Address - Phone:435-688-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7717207Q00000X
UT9424738-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70445FMedicaid
CACMM70445FMedicaid