Provider Demographics
NPI:1992781660
Name:COUNCE, CHARLES MARCIAL (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARCIAL
Last Name:COUNCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 S LEGEND LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1793
Mailing Address - Country:US
Mailing Address - Phone:719-547-7461
Mailing Address - Fax:719-547-7461
Practice Address - Street 1:732 S LEGEND LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81007-1793
Practice Address - Country:US
Practice Address - Phone:719-547-7461
Practice Address - Fax:719-547-7461
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF-03042Medicare UPIN