Provider Demographics
NPI:1306876651
Name:GREENE, CHARLES C (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:GREENE
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 1:11512 LAKE MEAD AVE UNIT 531
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9733
Mailing Address - Country:US
Mailing Address - Phone:904-419-2054
Mailing Address - Fax:904-419-2057
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:SUITE 531
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-419-2054
Practice Address - Fax:904-419-2057
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82871207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264139900Medicaid
FLGZ403ZMedicare PIN
FLGZ403YMedicare PIN
FLH43194Medicare UPIN