Provider Demographics
NPI:1760483036
Name:LASTRAPES, CHARLES J (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:LASTRAPES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:408 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5725
Mailing Address - Country:US
Mailing Address - Phone:573-332-0808
Mailing Address - Fax:573-339-7945
Practice Address - Street 1:408 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5725
Practice Address - Country:US
Practice Address - Phone:573-332-0808
Practice Address - Fax:573-339-7945
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MODO112343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1760483036Medicaid
MOG00152Medicare UPIN
MO618815006Medicare PIN