Provider Demographics
NPI:1477586766
Name:KEBLUSEK, CHARLES W (MD,FACOG,PC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:KEBLUSEK
Suffix:
Gender:M
Credentials:MD,FACOG,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 TRITON SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-7140
Mailing Address - Country:US
Mailing Address - Phone:804-379-7579
Mailing Address - Fax:804-379-9701
Practice Address - Street 1:1409 HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2603
Practice Address - Country:US
Practice Address - Phone:804-706-5827
Practice Address - Fax:804-706-5819
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027033207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477586766Medicaid
VA006206841Medicaid
VAP00604256Medicare PIN
VA006206841Medicaid
VA1477586766Medicaid
VA017070J52Medicare PIN