Healthcare Provider Details

I. General information

NPI: 1629027784
Provider Name (Legal Business Name): CHARLES HALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3356 KING EDWARDS CT
EUGENE OR
97401-8513
US

IV. Provider business mailing address

2020 PALOMINO LN # 100
LAS VEGAS NV
89106-4894
US

V. Phone/Fax

Practice location:
  • Phone: 702-588-3438
  • Fax: 702-384-1815
Mailing address:
  • Phone: 702-759-8600
  • Fax: 702-384-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5485
License Number StateNV

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200470500A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier200290010
Identifier TypeMEDICAID
Identifier StateNV
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: