Provider Demographics
NPI:1851315519
Name:REQUARD, CHARLES KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:REQUARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1961 N CORTE EL RANCHO MERLITA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4493
Mailing Address - Country:US
Mailing Address - Phone:520-780-1281
Mailing Address - Fax:520-547-5959
Practice Address - Street 1:5515 E 5TH ST
Practice Address - Street 2:C/O ARIZONA COMMUNITY PHYSICIANS
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2415
Practice Address - Country:US
Practice Address - Phone:520-298-1138
Practice Address - Fax:520-547-5959
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ137252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8552002Medicaid
E20082Medicare UPIN
AZ000346703Medicare ID - Type Unspecified