Provider Demographics
NPI: | 1164481727 |
---|---|
Name: | FORD, CHARLES W JR (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | CHARLES |
Middle Name: | W |
Last Name: | FORD |
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: | 870 STATE FARM RD |
Mailing Address - Street 2: | SUITE 101 |
Mailing Address - City: | BOONE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28607-4861 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 828-264-4545 |
Mailing Address - Fax: | 282-264-4544 |
Practice Address - Street 1: | 870 STATE FARM RD |
Practice Address - Street 2: | SUITE 101 |
Practice Address - City: | BOONE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28607-4861 |
Practice Address - Country: | US |
Practice Address - Phone: | 828-264-4545 |
Practice Address - Fax: | 282-264-4544 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-22 |
Last Update Date: | 2014-03-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 94-00056 | 207Y00000X, 207YX0602X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | |
No | 207YX0602X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 8932979 | Medicaid | |
2325244 | Medicare ID - Type Unspecified | ||
NC | 8932979 | Medicaid |