Provider Demographics
NPI:1053427716
Name:ISE, CHARLEEN L (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLEEN
Middle Name:L
Last Name:ISE
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:PO BOX 530968
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33747-0968
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-828-0723
Practice Address - Street 1:1120 PINELLAS BAYWAY
Practice Address - Street 2:STE 200
Practice Address - City:TIERRA VERDE
Practice Address - State:FL
Practice Address - Zip Code:33715-1505
Practice Address - Country:US
Practice Address - Phone:727-867-5480
Practice Address - Fax:727-867-5470
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055512207PE0005X
FLME555122083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101276100Medicaid
0100444OtherEVERCARE
267080OtherAVMED
P00306082OtherRAILROAD MEDICARE
FL09781OtherBCBS
4045500OtherAETNA
267080OtherAVMED
4045500OtherAETNA
FL09781WMedicare PIN