Provider Demographics
NPI:1487656443
Name:BARTHOLOME, CHARLES WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BARTHOLOME
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 1:1808 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2243
Mailing Address - Country:US
Mailing Address - Phone:765-288-8188
Mailing Address - Fax:765-282-7242
Practice Address - Street 1:1808 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2243
Practice Address - Country:US
Practice Address - Phone:765-288-8188
Practice Address - Fax:765-282-7242
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN100348140207N00000X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070002789OtherRAILROAD MEDICARE
IN000000084070OtherBLUE CROSS/BLUE SHIELD
IN100348140Medicaid
INE08081Medicare UPIN
IN100348140Medicaid