Provider Demographics
NPI:1194718270
Name:MAULDIN, CHARLES C JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:C
Last Name:MAULDIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5015 S GLENHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7800
Mailing Address - Country:US
Mailing Address - Phone:417-881-7808
Mailing Address - Fax:
Practice Address - Street 1:1308 N GLENSTONE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-2130
Practice Address - Country:US
Practice Address - Phone:417-864-4100
Practice Address - Fax:417-863-8697
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR6J28208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202697900Medicaid
MO43151887165802A005OtherTRIWEST
MOACS#140740000OtherUS POSTAL SERVICE
MO2079425OtherFIRST HEALTH
MO19288OtherBLUE CROSS/BLUE SHIELD
MO26D1025378OtherCLIA
MO9378408OtherPHCS
MOACS#140740000OtherUS POSTAL SERVICE
MO26D1025378OtherCLIA