Provider Demographics
NPI:1912937764
Name:MIRABILE, CHARLES JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOHN
Last Name:MIRABILE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 857
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-0857
Mailing Address - Country:US
Mailing Address - Phone:304-425-8183
Mailing Address - Fax:304-487-5612
Practice Address - Street 1:100 NEW HOPE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2143
Practice Address - Country:US
Practice Address - Phone:304-425-8183
Practice Address - Fax:304-487-5612
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0083600000Medicaid
A72152Medicare UPIN
MI0504332Medicare ID - Type Unspecified