Provider Demographics
NPI:1891069233
Name:CHARLES, LIZA N (MD)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:N
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:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:
Practice Address - Street 1:19701 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4818
Practice Address - Country:US
Practice Address - Phone:239-314-1660
Practice Address - Fax:239-425-6404
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118536208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011911100Medicaid
FL011911100Medicaid