Provider Demographics
NPI:1447205448
Name:HIGGS-COULTHARD, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:HIGGS-COULTHARD
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 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:611 E DOUGLAS RD STE 406
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:574-335-6580
Practice Address - Fax:574-335-0796
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325690AMedicaid
IN100325690AMedicaid
IN738460001Medicare PIN
IN000000215740OtherBCBS
INF57893Medicare UPIN
IN187580DMedicare PIN
ININ1133003Medicare PIN