Healthcare Provider Details

I. General information

NPI: 1598991762
Provider Name (Legal Business Name): CHARLES S. EVERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7335 E. CALLE MESETA SERENA
TUCSON AZ
85750-0946
US

IV. Provider business mailing address

7335 E. CALLE MESETA SERENA
TUCSON AZ
85750-0946
US

V. Phone/Fax

Practice location:
  • Phone: 520-529-0004
  • Fax: 520-529-0008
Mailing address:
  • Phone: 520-529-0004
  • Fax: 520-529-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6962
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number630272
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: