Provider Demographics
NPI:1790780930
Name:SMITH, CHARLES BROOKS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BROOKS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:BROOKS
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1204 MEDICAL PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1204 MEDICAL PLAZA CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5653
Practice Address - Country:US
Practice Address - Phone:817-573-5688
Practice Address - Fax:817-573-5760
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00614WMedicare PIN
TX8B8315Medicare PIN