Provider Demographics
NPI:1659314763
Name:LIN, CHARLIE T (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:T
Last Name:LIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:TZUCHANG
Other - Middle Name:
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-838-8265
Mailing Address - Fax:
Practice Address - Street 1:888 S RANCHO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3810
Practice Address - Country:US
Practice Address - Phone:702-838-8265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7717207Q00000X
UT9424738-1204207Q00000X
NVDO2835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70445FMedicaid
CACMM70445FMedicaid