Provider Demographics
NPI:1376659490
Name:CORAM, CHARLES DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:CORAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 ALBIA RD
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3708
Mailing Address - Country:US
Mailing Address - Phone:641-682-3993
Mailing Address - Fax:
Practice Address - Street 1:1941 ALBIA RD
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3708
Practice Address - Country:US
Practice Address - Phone:641-682-3993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06164111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0185058Medicaid
IA48315Medicare UPIN
IA48315Medicare ID - Type Unspecified