Provider Demographics
NPI:1841291861
Name:MAILE, CHARLES W (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:MAILE
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 1448
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0877
Mailing Address - Country:US
Mailing Address - Phone:208-263-1441
Mailing Address - Fax:208-265-1278
Practice Address - Street 1:520 NORTH THIRD
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1507
Practice Address - Country:US
Practice Address - Phone:208-263-1441
Practice Address - Fax:208-265-1278
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN256182085U0001X, 2085B0100X, 2085R0202X
IDM95732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807532600Medicaid
MN787573800Medicaid
300000064Medicare ID - Type Unspecified
ID807532600Medicaid