Provider Demographics
NPI:1497117717
Name:CLOSSON, CHARLES FREDERICK
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:CLOSSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40423-0990
Mailing Address - Country:US
Mailing Address - Phone:859-239-5870
Mailing Address - Fax:
Practice Address - Street 1:216 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1858
Practice Address - Country:US
Practice Address - Phone:859-239-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine