Provider Demographics
NPI:1780741249
Name:MIRABILE, CHARLES S JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:MIRABILE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:18 UPPER MAIN ST
Mailing Address - City:SHARON
Mailing Address - State:CT
Mailing Address - Zip Code:06069
Mailing Address - Country:US
Mailing Address - Phone:860-364-0740
Mailing Address - Fax:860-364-1920
Practice Address - Street 1:18 UPPER MAIN ST
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069
Practice Address - Country:US
Practice Address - Phone:860-364-0740
Practice Address - Fax:860-364-1920
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT119032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C59525Medicare UPIN