Basic Information
Provider Information | |||||||||
NPI: | 1063588119 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAY | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | WAYNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5915 VISTA DEL MAR | ||||||||
Address2: |   | ||||||||
City: | YORBA LINDA | ||||||||
State: | CA | ||||||||
PostalCode: | 928873223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7149700712 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12291 WASHINGTON BLVD | ||||||||
Address2: | SUITE 500 | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906062500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626982541 | ||||||||
FaxNumber: | 5626983541 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G40919 | CA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.