Provider Demographics
NPI:1679503189
Name:SIMS, CHARLES LEWIS JR (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEWIS
Last Name:SIMS
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GOLDEN SHR
Mailing Address - Street 2:MOLINA MEDICAL CENTERS SMO
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4202
Mailing Address - Country:US
Mailing Address - Phone:909-624-4952
Mailing Address - Fax:909-621-9498
Practice Address - Street 1:351 N MTN VIEW AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0010
Practice Address - Country:US
Practice Address - Phone:909-387-6222
Practice Address - Fax:909-387-6228
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10600OtherMEDI-CAL
0PA106000Medicare ID - Type Unspecified
A21823Medicare UPIN