Provider Demographics
NPI:1508875071
Name:CHARLESWORTH, DOUGLAS ALLAN
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALLAN
Last Name:CHARLESWORTH
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 1:2104 W SAYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-5709
Mailing Address - Country:US
Mailing Address - Phone:574-534-4023
Mailing Address - Fax:
Practice Address - Street 1:2104 W SAYBROOK DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-5709
Practice Address - Country:US
Practice Address - Phone:574-534-4023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036465A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine