Provider Demographics
NPI:1710913546
Name:CHARLES, JOSEPH THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:THOMAS
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 SE TIFFANY AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7554
Mailing Address - Country:US
Mailing Address - Phone:772-398-2233
Mailing Address - Fax:772-398-2244
Practice Address - Street 1:1825 SE TIFFANY AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7554
Practice Address - Country:US
Practice Address - Phone:772-398-2233
Practice Address - Fax:772-398-2244
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME547602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039279100Medicaid
FL08756OtherBCBS PROVIDER NUMBER
FL08756OtherBCBS PROVIDER NUMBER
FLE22608Medicare UPIN