Provider Demographics
NPI:1407878770
Name:DUVALL, CHARLES S (AA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:DUVALL
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6260
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67-000109367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2539917Medicaid
OH000000232162OtherUNISON
OH000000515964OtherANTHEM
OH414965OtherWELLCARE MEDICAID
OH7733967OtherAETNA
OHP00444996OtherRAILROAD MEDICARE
OH0583328OtherBCMH
OH7733967OtherAETNA
OH2539917Medicaid