Provider Demographics
NPI:1447248380
Name:BRADY, CHARLES F (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:BRADY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 NOGAL PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:903 C NORTH 5TH STREET
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87016
Practice Address - Country:US
Practice Address - Phone:505-384-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8928207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00400MOtherBLUE CROSS BLUE SHIELD OF NEW MEXICO
NM000E5032Medicaid
TX119038103Medicaid
NM36224OtherPRESBYTERIAN HEALTH PLAN
NMPROVP11371OtherMOLINA HEALTHCARE
NM36224OtherPRESBYTERIAN HEALTH PLAN
TX87721JMedicare ID - Type Unspecified
TX119038103Medicaid
NMPROVP11371OtherMOLINA HEALTHCARE