Provider Demographics
NPI:1588695654
Name:SECREST, CHARLES L (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:SECREST
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 1:1101 6TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4306
Mailing Address - Country:US
Mailing Address - Phone:817-912-8570
Mailing Address - Fax:
Practice Address - Street 1:1101 6TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-912-8570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSB29973174400000X
MS11417208800000X
TXH2964208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1694304Medicaid
MS0115556Medicaid
MS02701861186OtherAMA
MS$$$$$$$$$AOtherBCBS OF MS
MS340000145Medicare PIN