Provider Demographics
NPI:1114998333
Name:STOTLER, CHARLES WILBUR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILBUR
Last Name:STOTLER
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 1:334 BLOOMFIELD ST
Mailing Address - Street 2:STE 205
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-266-8686
Mailing Address - Fax:814-266-6478
Practice Address - Street 1:334 BLOOMFIELD ST
Practice Address - Street 2:STE 205
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-266-8686
Practice Address - Fax:814-266-6478
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017069E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000746670003Medicaid
096835Medicare ID - Type UnspecifiedGROUP
PA000746670003Medicaid
058846UVNMedicare ID - Type Unspecified