Provider Demographics
NPI:1528251956
Name:GINN, CHARLES STEPHEN (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:STEPHEN
Last Name:GINN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 S 45TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8854
Mailing Address - Country:US
Mailing Address - Phone:479-531-7416
Mailing Address - Fax:888-371-5937
Practice Address - Street 1:5203 S 45TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8854
Practice Address - Country:US
Practice Address - Phone:479-531-7416
Practice Address - Fax:888-371-5937
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR243213ES0103X
MO2007022315390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185785717Medicaid
AR185785717Medicaid