=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326095381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES C CARTER MD DPH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 E BROADWAY ST SUITE 102
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-480-1600
-----------------------------------------------------
Fax | 580-480-1601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 575
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73522-0575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-480-1600
-----------------------------------------------------
Fax | 580-480-1601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHYSICIAN
-----------------------------------------------------
Name | DR. CHARLES C CARTER
-----------------------------------------------------
Credential | MD DPH
-----------------------------------------------------
Telephone | 580-480-1600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 19154
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------