Provider Demographics
NPI:1114030541
Name:STITES, CHARLOTTE GAY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:GAY
Last Name:STITES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 S HANCOCK ST APT B100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2449
Mailing Address - Country:US
Mailing Address - Phone:502-242-7458
Mailing Address - Fax:502-219-3673
Practice Address - Street 1:760 S HANCOCK ST APT B100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2449
Practice Address - Country:US
Practice Address - Phone:502-242-7458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34411208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64434111Medicaid
KY64434111Medicaid
KY0229815Medicare ID - Type Unspecified