Provider Demographics
NPI:1265582837
Name:OLISA, CHARLES O (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:O
Last Name:OLISA
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 1:445 E FM 1382
Mailing Address - Street 2:SUITE 3 - 265
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-5104
Mailing Address - Country:US
Mailing Address - Phone:469-744-8844
Mailing Address - Fax:
Practice Address - Street 1:445 E FM 1382
Practice Address - Street 2:SUITE 3- 265
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104
Practice Address - Country:US
Practice Address - Phone:469-744-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066108A207R00000X, 208M00000X
LAMD205030208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008839400Medicaid
IN11948268OtherCAQH
IN11948268OtherCAQH