MEDICARE: DR. CHARLES RICHARD MABRAY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	D3325	TX

General Provider Information

NPI Number	:	1255336798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES RICHARD MABRAY M.D.

Provider Business Mailing Address
First Line	:	115 MEDICAL DR
Second Line	:	STE 202
City	:	VICTORIA
State	:	TX
Zip	:	77904-3102
Country	:	US
Telephone Number	:	361-574-9697
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 MEDICAL DR
Second Line	:	STE 202
City	:	VICTORIA
State	:	TX
Zip	:	77904-3102
Country	:	US
Telephone Number	:	361-574-9697
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/12/2007

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