Individual
CHARLES L SECREST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1101 6TH AVE STE 110, FORT WORTH, TX 76104
(817) 912-8570
Mailing address
1101 6TH AVE STE 110, FORT WORTH, TX 76104-4306
(817) 912-8570
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
B29973
MS
208800000X
Urology Physician
11417
MS
208800000X
Urology Physician
Primary
H2964
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1694304
—
LA
Enumeration date
07/06/2006
Last updated
06/28/2019
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