Provider Demographics
NPI:1477546976
Name:HORSLEY, CHARLES D (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:HORSLEY
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 1:1470 NORTH BROADWAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1206
Mailing Address - Country:US
Mailing Address - Phone:513-932-2686
Mailing Address - Fax:513-932-2706
Practice Address - Street 1:1470 NORTH BROADWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1206
Practice Address - Country:US
Practice Address - Phone:513-932-2686
Practice Address - Fax:513-932-2706
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-049880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0536370Medicaid
OH080007460Medicare PIN
OHA15635Medicare UPIN
OH0536370Medicaid