Provider Demographics
NPI:1144392499
Name:DEHAAN, CHARLES SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SCOTT
Last Name:DEHAAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:124 N WATER ST
Mailing Address - Street 2:208
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3960
Mailing Address - Country:US
Mailing Address - Phone:815-312-5810
Mailing Address - Fax:815-312-5811
Practice Address - Street 1:124 N WATER ST
Practice Address - Street 2:208
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3960
Practice Address - Country:US
Practice Address - Phone:815-312-5810
Practice Address - Fax:815-312-5811
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2013-12-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-064615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C44289Medicare UPIN