Provider Demographics
NPI:1730103664
Name:MAXVILL, CHARLES T JR (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:MAXVILL
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 WESTPARK WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3742
Mailing Address - Country:US
Mailing Address - Phone:682-236-3656
Mailing Address - Fax:855-813-9308
Practice Address - Street 1:251 WESTPARK WAY STE 210
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3742
Practice Address - Country:US
Practice Address - Phone:682-236-3656
Practice Address - Fax:855-813-9308
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5299207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131808108Medicaid
TX131808109Medicaid
TX131808110Medicaid
TX1318080107Medicaid
TX131808114Medicaid
TX8L9629Medicare PIN
TX8L9543Medicare PIN
TX1318080107Medicaid
TX131808110Medicaid
TX131808108Medicaid
TX8L9544Medicare PIN