Provider Demographics
NPI:1902877780
Name:SMITH, CHARLENE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1601 HIGHWAY 59 LOOP N STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-6687
Mailing Address - Country:US
Mailing Address - Phone:936-327-3937
Mailing Address - Fax:936-327-7847
Practice Address - Street 1:1601 HIGHWAY 59 LOOP N STE 100
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-6687
Practice Address - Country:US
Practice Address - Phone:936-327-3937
Practice Address - Fax:936-327-7847
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG3795207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132092107Medicaid
C21979Medicare UPIN
TX1210730001Medicare NSC
TX132092107Medicaid