Basic Information
| Provider Information | |||||||||
| NPI: | 1609845809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBBARD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JASON | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 E. 32ND ST. | ||||||||
| Address2: | STE 101 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78705 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1015 E 32ND ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787052707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124776341 | ||||||||
| FaxNumber: | 5122441013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1625 | TX | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 1625 | TX | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8H3950 | 01 | TX | BCBS OF TEXAS | OTHER | 158150601 | 05 | TX | MEDICAID |