Healthcare Provider Details

I. General information

NPI: 1891069233
Provider Name (Legal Business Name): LIZA N CHARLES M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19701 S TAMIAMI TRL
FORT MYERS FL
33908-4818
US

IV. Provider business mailing address

PO BOX 919771
ORLANDO FL
32891-9771
US

V. Phone/Fax

Practice location:
  • Phone: 239-314-1660
  • Fax: 239-425-6404
Mailing address:
  • Phone: 239-278-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME118536
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: