Provider Demographics
NPI:1376075507
Name:CHARLES, JEAN ELIZZE MABUTE (DO)
Entity type:Individual
Prefix:DR
First Name:JEAN ELIZZE
Middle Name:MABUTE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JEAN ELIZZE
Other - Middle Name:
Other - Last Name:MABUTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4235 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1337
Mailing Address - Country:US
Mailing Address - Phone:512-279-3376
Mailing Address - Fax:512-666-3244
Practice Address - Street 1:4235 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1337
Practice Address - Country:US
Practice Address - Phone:512-279-3376
Practice Address - Fax:512-666-3244
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT1316207N00000X
TXBP20065105390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program