Basic Information
| Provider Information | |||||||||
| NPI: | 1114994621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EWOH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761610205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173783699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 8TH AVE STE 502 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358478 | ||||||||
| FaxNumber: | 8178829910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 64486 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 27612 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | Q1399 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | Q1399 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1D1318 | 01 | MS | MEDICARE | OTHER | 354657409 | 05 | TX | MEDICAID |