Basic Information
| Provider Information | |||||||||
| NPI: | 1659464550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOPARKAR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PH.D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3730 KIRBY DR | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770983905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137950705 | ||||||||
| FaxNumber: | 7138070630 | ||||||||
| Practice Location | |||||||||
| Address1: | 3730 KIRBY DR | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770983905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137950705 | ||||||||
| FaxNumber: | 7138070630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0200X | J6247 | TX | Y |
ID Information
| ID | Type | State | Issuer | Description | 1659464550 | 01 | TX | NPI | OTHER | 1235222167 | 01 | TX | GROUP NPI | OTHER | 135956402 | 05 | TX | MEDICAID | J6247 | 01 | TX STATE LICENSE | OTHER |