Provider Demographics
NPI:1649810540
Name:CHARLES L CARR JR DO PA
Entity type:Organization
Organization Name:CHARLES L CARR JR DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:207-332-0774
Mailing Address - Street 1:3959 VAN DYKE RD # 259
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8025
Mailing Address - Country:US
Mailing Address - Phone:207-332-0774
Mailing Address - Fax:
Practice Address - Street 1:4335 CHEVAL BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5328
Practice Address - Country:US
Practice Address - Phone:207-332-0774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty