Provider Demographics
NPI:1538139712
Name:BLACHE, CHARLENE CARLA (MD)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:CARLA
Last Name:BLACHE
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 1:406 M NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1853
Mailing Address - Country:US
Mailing Address - Phone:229-241-0059
Mailing Address - Fax:229-241-2088
Practice Address - Street 1:406 M NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1853
Practice Address - Country:US
Practice Address - Phone:229-241-0059
Practice Address - Fax:229-241-2088
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045728208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000816593KMedicaid
GA000816593BMedicaid
GA000816593LMedicaid
GA000816593KMedicaid