Provider Demographics
NPI:1790777076
Name:CHARNOCK, EDWIN HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:HOWARD
Last Name:CHARNOCK
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 1:1441 N BECKLEY AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1201
Mailing Address - Country:US
Mailing Address - Phone:214-943-9300
Mailing Address - Fax:214-942-3549
Practice Address - Street 1:1001 ROBBIE MINCE WAY
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2012
Practice Address - Country:US
Practice Address - Phone:972-780-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG49092084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134735307Medicaid
TX87W861Medicare ID - Type Unspecified
TX134735307Medicaid