Provider Demographics
NPI:1144275959
Name:RACE, CHARLES MARK (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARK
Last Name:RACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:515-955-6767
Mailing Address - Fax:
Practice Address - Street 1:2539 MEDICAL DR
Practice Address - Street 2:STE 110
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8720
Practice Address - Country:US
Practice Address - Phone:575-434-2116
Practice Address - Fax:575-434-2051
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0724207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA35351OtherWELLMARK
IA36167OtherWELLMARK
IAF244880OtherMIDLANDS
IA1175OtherMIDLANDS
IADC9737OtherRR MEDICARE
IA9098947Medicaid
IAP00041350OtherRR MEDICARE
IA0425561Medicaid
IAF244880OtherMIDLANDS
IAI11029Medicare ID - Type Unspecified
IA36167OtherWELLMARK