Provider Demographics
NPI:1891791299
Name:PHILLIPS, CHARLES VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:VINCENT
Last Name:PHILLIPS
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 1:3838 SAN DIMAS ST
Mailing Address - Street 2:STE B-231
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2284
Mailing Address - Country:US
Mailing Address - Phone:661-665-0505
Mailing Address - Fax:661-665-7844
Practice Address - Street 1:3838 SAN DIMAS ST
Practice Address - Street 2:STE B-231
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2284
Practice Address - Country:US
Practice Address - Phone:661-665-0505
Practice Address - Fax:661-665-7844
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2015-02-25
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CAC37044208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020000590OtherMEDICARE RAILROAD
CAGR0062760Medicaid
CAZZZ43503ZMedicare ID - Type Unspecified
CAGR0062760Medicaid