Provider Demographics
NPI:1942293097
Name:CHARLES, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:CHARLES
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 1:1919 S WHEELING AVE
Mailing Address - Street 2:STE 606
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5635
Mailing Address - Country:US
Mailing Address - Phone:918-748-7676
Mailing Address - Fax:
Practice Address - Street 1:1919 S WHEELING AVE
Practice Address - Street 2:STE 606
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5635
Practice Address - Country:US
Practice Address - Phone:918-748-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5534208600000X
OK284452086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123647301Medicaid
TXE62531Medicare UPIN
TX123647301Medicaid