Healthcare Provider Details

I. General information

NPI: 1295048031
Provider Name (Legal Business Name): CHARLES PATRICK COYNE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 ANWIJO WAY
WARRENTON MO
63383-1388
US

IV. Provider business mailing address

521 ANWIJO WAY
WARRENTON MO
63383-1388
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-6103
  • Fax: 636-456-6124
Mailing address:
  • Phone: 636-456-6103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number201024955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: