Healthcare Provider Details
I. General information
NPI: 1053467894
Provider Name (Legal Business Name): CHARLES MILES MALISKA III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 01/26/2007
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:
III. Provider practice location address
2402 FRIST BLVD STE 204
FORT PIERCE FL
34950-4838
US
IV. Provider business mailing address
2402 FRIST BLVD STE 204
FORT PIERCE FL
34950-4838
US
V. Phone/Fax
- Phone: 772-462-3939
- Fax:
- Phone: 772-462-3939
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208600000X |
| Taxonomy | Surgery Physician |
| License Number | 27745 |
| License Number State | OK |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208600000X |
| Taxonomy | Surgery Physician |
| License Number | A99319 |
| License Number State | CA |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208600000X |
| Taxonomy | Surgery Physician |
| License Number | R2163 |
| License Number State | TX |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208600000X |
| Taxonomy | Surgery Physician |
| License Number | 303595 |
| License Number State | NY |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0102X |
| Taxonomy | Surgical Critical Care Physician |
| License Number | R2163 |
| License Number State | TX |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0102X |
| Taxonomy | Surgical Critical Care Physician |
| License Number | 27745 |
| License Number State | OK |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0102X |
| Taxonomy | Surgical Critical Care Physician |
| License Number | 303595 |
| License Number State | NY |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0102X |
| Taxonomy | Surgical Critical Care Physician |
| License Number | A99319 |
| License Number State | CA |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0127X |
| Taxonomy | Trauma Surgery Physician |
| License Number | 27745 |
| License Number State | OK |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0127X |
| Taxonomy | Trauma Surgery Physician |
| License Number | 303595 |
| License Number State | NY |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0127X |
| Taxonomy | Trauma Surgery Physician |
| License Number | R2163 |
| License Number State | TX |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 2086S0127X |
| Taxonomy | Trauma Surgery Physician |
| License Number | A99319 |
| License Number State | CA |
| # 13 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 2086S0102X |
| Taxonomy | Surgical Critical Care Physician |
| License Number | ME150816 |
| License Number State | FL |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
