Provider Demographics
NPI:1750349858
Name:HIMMLER, CHARLES WESLEY (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WESLEY
Last Name:HIMMLER
Suffix:
Gender:M
Credentials:DO
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 359
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173
Mailing Address - Country:US
Mailing Address - Phone:501-796-8484
Mailing Address - Fax:501-796-2453
Practice Address - Street 1:1159 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173
Practice Address - Country:US
Practice Address - Phone:501-796-8484
Practice Address - Fax:501-796-2453
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116681003Medicaid
ARB58247Medicare UPIN
AR080017971Medicare PIN
AR116681003Medicaid