Provider Demographics
NPI:1093713950
Name:DRISCOLL, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:DRISCOLL
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 1:1204 FENWICK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2323 MEMORIAL AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2661
Practice Address - Country:US
Practice Address - Phone:434-947-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101224139207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0056-4239-6Medicaid
01-02054OtherUNITED HEALTHCARE PROVIDE
VA005644011Medicaid
216430OtherANTHEM PROVIDER NUMBER
56-4401-1OtherVA PREMIER PROVIDER NUMBE
9035997OtherCIGNA PROVIDER NUMBER
93672OtherMEDCOST PROVIDER NUMBER
541457983OtherTRICARE PROVIDER NUMBER
41816OtherSENTARA/OPTIMA PROVIDER N
541457983OtherPCHP PROVIDER NUMBER
248773OtherSOUTHERN HEALTH PROVIDER
VA0056-4239-6Medicaid
93672OtherMEDCOST PROVIDER NUMBER
VAE04900Medicare UPIN