Healthcare Provider Details

I. General information

NPI: 1629016126
Provider Name (Legal Business Name): CHARLES M WREN II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

IV. Provider business mailing address

PO BOX 1530
SALTILLO MS
38866-1530
US

V. Phone/Fax

Practice location:
  • Phone: 662-891-2999
  • Fax:
Mailing address:
  • Phone: 662-891-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number14798
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number14798
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1619
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: