Provider Demographics
NPI:1366523722
Name:CHARLIE, JIMMIE R (MD)
Entity type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:R
Last Name:CHARLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0340
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:505-867-6527
Practice Address - Street 1:85 WEST HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO
Practice Address - State:NM
Practice Address - Zip Code:87502-0340
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:505-465-3060
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM20020019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85534862Medicaid
NM85534862Medicaid