Provider Demographics
NPI:1245232156
Name:WHALEN, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:WHALEN
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 1:2514 E DUPONT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1619
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:2514 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1623
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051941A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000111208OtherANTHEM
IN200250710Medicaid
OH3045565Medicaid
IN000000693552OtherANTHEM
INM400039492Medicare PIN
IN000000693552OtherANTHEM
OH3045565Medicaid