Provider Demographics
NPI:1306999123
Name:WOMACK, CHARLES E (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:WOMACK
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 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-254-4199
Mailing Address - Fax:386-947-4680
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4199
Practice Address - Fax:386-947-4680
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88146208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277522100Medicaid
FLME88146OtherMEDICAL LICENSE
FL277522100Medicaid