Provider Demographics
NPI:1083671135
Name:CHARLES OTIS BOYETTE MD
Entity Type:Organization
Organization Name:CHARLES OTIS BOYETTE MD
Other - Org Name:CO BOYETTE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:OTIS
Authorized Official - Last Name:BOYETTE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:252-943-6144
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:BELHAVEN
Mailing Address - State:NC
Mailing Address - Zip Code:27810-0310
Mailing Address - Country:US
Mailing Address - Phone:252-943-6144
Mailing Address - Fax:252-943-2038
Practice Address - Street 1:216 HASLIN STREET
Practice Address - Street 2:
Practice Address - City:BELHAVEN
Practice Address - State:NC
Practice Address - Zip Code:27810
Practice Address - Country:US
Practice Address - Phone:252-943-6144
Practice Address - Fax:252-943-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890201WMedicaid
NC0320740001Medicare NSC
2319230Medicare ID - Type Unspecified