Provider Demographics
NPI:1255643136
Name:CHARLES, TRAVIS BRANDON (DO)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:BRANDON
Last Name:CHARLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N. 500 W ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:555 W SR 164
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653
Practice Address - Country:US
Practice Address - Phone:385-265-6050
Practice Address - Fax:801-465-3287
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010021663207Q00000X
AZ006233207Q00000X
UT12403966-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ840074Medicaid
Z162010Medicare PIN