Basic Information
| Provider Information | |||||||||
| NPI: | 1235136565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6622 N 91ST AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853052569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027596883 | ||||||||
| FaxNumber: | 6022243315 | ||||||||
| Practice Location | |||||||||
| Address1: | 4511 N CAMPBELL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857186424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205296500 | ||||||||
| FaxNumber: | 5202097337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 62734 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 200199750A | 05 | IN | MEDICAID | 090305 | 05 | AZ | MEDICAID |