Provider Demographics
NPI:1972028249
Name:RECORD, CHARLSIE
Entity Type:Individual
Prefix:
First Name:CHARLSIE
Middle Name:
Last Name:RECORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 WOODROW CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73169-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10413 GREENBRIAR PKWY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7656
Practice Address - Country:US
Practice Address - Phone:405-691-4665
Practice Address - Fax:405-378-7628
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine