Provider Demographics
NPI:1134187230
Name:PHILLIPS, CHARLES EDWARD (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:PHILLIPS
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 1:2035 PROFESSIONAL CTR DR
Mailing Address - Street 2:STE C
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-272-0384
Mailing Address - Fax:904-272-6748
Practice Address - Street 1:2035 PROFESSIONAL CTR DR
Practice Address - Street 2:STE C
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-272-0384
Practice Address - Fax:904-272-6748
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME32937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037423700Medicaid
FL037423700Medicaid
D61567Medicare UPIN