Provider Demographics
NPI:1003808361
Name:DOUCHY, CHARLES JACOB (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JACOB
Last Name:DOUCHY
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 1:3850 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4807
Mailing Address - Country:US
Mailing Address - Phone:770-814-8222
Mailing Address - Fax:678-205-5111
Practice Address - Street 1:3850 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4807
Practice Address - Country:US
Practice Address - Phone:770-814-8222
Practice Address - Fax:678-205-5111
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040052207N00000X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00663396BMedicaid
GA2498075OtherAETNA
GA912915OtherBCBS
GA000663396EMedicaid
GA070014632OtherRR MEDICARE
GA000663396FMedicaid
GA070014632OtherRR MEDICARE
GA000663396EMedicaid
GA07BBSHFMedicare PIN
GA000663396EMedicaid