Provider Demographics
NPI:1679690101
Name:BOULDIN, CHARLES EDWARD (RPT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:BOULDIN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4749 S EASON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6547
Mailing Address - Country:US
Mailing Address - Phone:662-842-3336
Mailing Address - Fax:662-842-3363
Practice Address - Street 1:4749 S EASON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6547
Practice Address - Country:US
Practice Address - Phone:662-842-3336
Practice Address - Fax:662-842-3363
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS650000011Medicare ID - Type Unspecified