Provider Demographics
NPI:1750642153
Name:CHARLES, CEROLA GUERDIE (MD)
Entity Type:Individual
Prefix:
First Name:CEROLA
Middle Name:GUERDIE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5416 E SOUTHERN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3622
Mailing Address - Country:US
Mailing Address - Phone:303-283-5991
Mailing Address - Fax:
Practice Address - Street 1:5416 E SOUTHERN AVE STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3622
Practice Address - Country:US
Practice Address - Phone:303-283-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0055936208D00000X
AZ584432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice