Provider Demographics
NPI:1518183284
Name:CROTEAU, CHARLES LAWRENCE (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LAWRENCE
Last Name:CROTEAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 NE HOYT ST STE 625
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2990
Mailing Address - Country:US
Mailing Address - Phone:503-731-2900
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST STE 625
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2990
Practice Address - Country:US
Practice Address - Phone:503-731-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340114892085R0202X
ORDO2183942085R0202X
MI51010160892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDO218394OtherOREGON MEDICAL LICENSE
MI1518183284Medicaid
OH34011489OtherOHIO MEDICAL LICENSE
MI5101016089OtherMICHIGAN MEDICAL LICENSE
OHPENDINGMedicaid
OHPENDINGMedicaid