Provider Demographics
NPI:1396717039
Name:MIMS, CHARLES H (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:MIMS
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 1:4411 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3832
Mailing Address - Country:US
Mailing Address - Phone:210-595-5326
Mailing Address - Fax:210-614-8740
Practice Address - Street 1:4411 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3822
Practice Address - Country:US
Practice Address - Phone:210-595-5326
Practice Address - Fax:210-614-8740
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4230207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD4230OtherSTATE LICESNE
TXB24917Medicare UPIN
TXD4230OtherSTATE LICESNE