Provider Demographics
NPI:1497868954
Name:CHARLESWORTH, AMY SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:SUE
Last Name:CHARLESWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 SOUNDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28570-5041
Mailing Address - Country:US
Mailing Address - Phone:252-725-9555
Mailing Address - Fax:252-565-0545
Practice Address - Street 1:135 SOUNDVIEW DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NC
Practice Address - Zip Code:28570-5041
Practice Address - Country:US
Practice Address - Phone:252-725-9555
Practice Address - Fax:252-565-0545
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400309207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902419Medicaid
NC5902419Medicaid
NC2048291Medicare ID - Type UnspecifiedPROVIDER NUMBER