Healthcare Provider Details

I. General information

NPI: 1053373662
Provider Name (Legal Business Name): CHARLES OZBORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 VETERANS MEMORIAL BLVD
EUPORA MS
39744-2064
US

IV. Provider business mailing address

1301 VETERANS MEMORIAL BLVD
EUPORA MS
39744-2064
US

V. Phone/Fax

Practice location:
  • Phone: 662-258-7200
  • Fax: 662-258-5871
Mailing address:
  • Phone: 662-258-7200
  • Fax: 662-258-5871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05006
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: