Provider Demographics
NPI:1306841341
Name:WALLER, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WALLER
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 1:218 BASS LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5824
Mailing Address - Country:US
Mailing Address - Phone:270-556-3239
Mailing Address - Fax:270-354-5865
Practice Address - Street 1:218 BASS LN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5824
Practice Address - Country:US
Practice Address - Phone:270-556-3239
Practice Address - Fax:270-354-5865
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29738208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4047217Medicaid
KY64297385Medicaid
TN4047217Medicaid
KY64297385Medicaid
KY0935608Medicare PIN
KY0924401Medicare ID - Type Unspecified