Provider Demographics
NPI:1740269257
Name:PHILLIPS, CHARLES ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLAN
Last Name:PHILLIPS
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:PO BOX 201606
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1606
Mailing Address - Country:US
Mailing Address - Phone:972-519-1940
Mailing Address - Fax:
Practice Address - Street 1:3301 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2908
Practice Address - Country:US
Practice Address - Phone:817-472-4869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4436207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85160YOtherBCBS
TX140249728Medicaid
TX85489FOtherBCBS
TX930091997OtherMEDICARE RAILROAD
TX140249722Medicaid
TN930089501OtherRAILROAD
TX140249721Medicaid
TX930092000OtherMEDICARE RAILROAD
TX140249734Medicaid
TX83172YOtherBCBS
TX930091997OtherMEDICARE RAILROAD
TX83172YOtherBCBS
TXF66984Medicare UPIN
TX85160YOtherBCBS