MEDICARE: CHARLES HARRY RICHARD DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS8590	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497766158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES HARRY RICHARD DO

Provider Business Mailing Address
First Line	:	1528 NE 4TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1036
Country	:	US
Telephone Number	:	954-467-8855
Fax Number	:	954-467-8857

Provider Business Practice Location Address
First Line	:	1528 NE 4TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1036
Country	:	US
Telephone Number	:	954-467-8855
Fax Number	:	954-467-8857

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	09/28/2012

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