Provider Demographics
NPI:1144203092
Name:SMALLING, CHARLES RONALD JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RONALD
Last Name:SMALLING
Suffix:JR
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-589-3100
Mailing Address - Fax:740-566-4049
Practice Address - Street 1:2131 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-566-4049
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055546A207N00000X, 207NS0135X
SC27830207N00000X, 207ND0900X, 207NS0135X
OH35.088883207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2723815Medicaid
WV3810007810Medicaid
OH2723815OtherOH MEDICAID MOLINA
OHP00362716OtherRAILROAD MEDICARE
OH000000204802OtherOH MEDICAID UNISON
OH310917085159OtherOH MEDICAID CARESOURCE
OHI33564Medicare UPIN
OH2723815Medicaid