Provider Demographics
NPI:1033112453
Name:BECKNELL, CHARLIE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:BECKNELL
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 1:250 FOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1888
Mailing Address - Country:US
Mailing Address - Phone:859-263-4444
Mailing Address - Fax:859-254-1814
Practice Address - Street 1:250 FOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-263-4444
Practice Address - Fax:859-254-1814
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21532207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0300056OtherUNITED HEALTHCARE
C03007OtherCUMBERLAND HEALTHCARE
000000044793OtherANTHEM
KY64215320Medicaid
000000044793OtherANTHEM
KY0300056OtherUNITED HEALTHCARE