Provider Demographics
NPI:1164486486
Name:PORTERFIELD, CHARLES EDMOND (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDMOND
Last Name:PORTERFIELD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-1307
Mailing Address - Country:US
Mailing Address - Phone:304-255-5710
Mailing Address - Fax:304-255-5702
Practice Address - Street 1:3771 ROBERT C BYRD DRIVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-5710
Practice Address - Fax:304-255-5702
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1084207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
155429OtherUMWA FUNDS
WV001706070OtherBCBS
WV0070983001Medicaid
WV4245814OtherAETNA
256325OtherFEDERAL DOL
WV0070983001Medicaid
P00171545Medicare ID - Type UnspecifiedRR
WV4245814OtherAETNA