Provider Demographics
NPI:1932588233
Name:CHARLES, DOMONIQUE (MD)
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6840
Mailing Address - Country:US
Mailing Address - Phone:478-633-7600
Mailing Address - Fax:
Practice Address - Street 1:744 1ST ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-633-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA081118208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics