Provider Demographics
NPI:1164402640
Name:HUMPHREY, CHARLES C (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:HUMPHREY
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 1:12 BATES ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7675
Mailing Address - Country:US
Mailing Address - Phone:207-786-3571
Mailing Address - Fax:207-783-3362
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7007
Practice Address - Country:US
Practice Address - Phone:207-795-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0126962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology