Provider Demographics
NPI:1669680260
Name:CHARLES R. HUMPHREY, M.D.,INC
Entity Type:Organization
Organization Name:CHARLES R. HUMPHREY, M.D.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-355-2207
Mailing Address - Street 1:PO BOX 1946
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-1946
Mailing Address - Country:US
Mailing Address - Phone:760-355-2207
Mailing Address - Fax:760-355-2207
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:760-355-2207
Practice Address - Fax:760-355-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23919208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G239190Medicaid
CAW1580OtherMEDICARE ID
CA00G239190Medicaid