Provider Demographics
NPI:1164421145
Name:SHOOKS, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:SHOOKS
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 1:90 QUARRY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1225
Mailing Address - Country:US
Mailing Address - Phone:860-456-2246
Mailing Address - Fax:860-450-1660
Practice Address - Street 1:90 QUARRY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1225
Practice Address - Country:US
Practice Address - Phone:860-456-2246
Practice Address - Fax:860-450-1660
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1168244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1168244OtherSTATE LICENSE
CT1168244OtherSTATE LICENSE
B39060Medicare UPIN