Healthcare Provider Details

I. General information

NPI: 1417931940
Provider Name (Legal Business Name): CHARLES PHILLIP FAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 80 10502 APO AP 96367-0001
KADENA AB OKINAWA
96367
JP

IV. Provider business mailing address

PSC 80 10502 APO AP 96367-0001
KADENA AB OKINAWA
96367
JP

V. Phone/Fax

Practice location:
  • Phone: 6305558
  • Fax:
Mailing address:
  • Phone: 6305558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberK5522
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: