Provider Demographics
NPI:1730514225
Name:MAHAN, CHARLES SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SAMUEL
Last Name:MAHAN
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 1:3111 E. FLETCHER AV.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611
Mailing Address - Country:US
Mailing Address - Phone:813-988-1259
Mailing Address - Fax:813-974-8889
Practice Address - Street 1:3111 E. FLETCHER AV.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611
Practice Address - Country:US
Practice Address - Phone:813-988-1259
Practice Address - Fax:813-974-8889
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26199207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology