Provider Demographics
NPI:1700856945
Name:MYERS, CHARLES MORAN SR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MORAN
Last Name:MYERS
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:571 HIDDEN LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:POWDERLY
Mailing Address - State:TX
Mailing Address - Zip Code:75473-3718
Mailing Address - Country:US
Mailing Address - Phone:903-732-3840
Mailing Address - Fax:903-732-9901
Practice Address - Street 1:1325 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3333
Practice Address - Country:US
Practice Address - Phone:361-729-0646
Practice Address - Fax:361-729-8854
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3352207P00000X, 207V00000X
TXD-3352208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC19749Medicare UPIN