Provider Demographics
NPI:1053373662
Name:OZBORN, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:OZBORN
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 1:1301 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-2064
Mailing Address - Country:US
Mailing Address - Phone:662-258-7200
Mailing Address - Fax:662-258-5871
Practice Address - Street 1:1301 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2064
Practice Address - Country:US
Practice Address - Phone:662-258-7200
Practice Address - Fax:662-258-5871
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011972Medicaid
MS00011972Medicaid
MS080001700Medicare ID - Type Unspecified