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General NPI Number Information
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NPI Number | 1588695654
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Entity Type | Individual
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Provider Name | CHARLES L SECREST MD
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Gender | Male
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 06/28/2019
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Provider Practice Location Address
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Address Line | 1101 6TH AVE STE 110
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City | FORT WORTH
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State | TX
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Zip | 76104
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Country | US
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Telephone | 817-912-8570
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 6TH AVE STE 110
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City | FORT WORTH
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State | TX
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Zip | 76104-4306
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Country | US
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Telephone | 817-912-8570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | B29973
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 11417
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | H2964
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License Number State | TX
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