Basic Information
| Provider Information | |||||||||
| NPI: | 1356390298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOUTZ | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8730 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761240730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2555 JIMMY JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ARTHUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776402007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097247389 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| 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 | 207P00000X | E0918 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 140113527 | 05 | TX | MEDICAID | 8R9680 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |