Provider Demographics
NPI:1215088364
Name:O'MARA, CHARLES S (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:O'MARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5105
Mailing Address - Fax:601-815-3322
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5105
Practice Address - Fax:601-815-3322
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09537208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0116204Medicaid
753068151OtherMHP
753068151OtherUHC
753068151017OtherTRICARE
753068151OtherUHC
MS$$$$$$$$$AOtherBCBS
MSP01435681Medicare PIN
753068151017OtherTRICARE
MSB31143Medicare UPIN