Provider Demographics
NPI:1639231087
Name:CARLISLE, DAVID CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2665
Mailing Address - Country:US
Mailing Address - Phone:304-624-7200
Mailing Address - Fax:304-554-0404
Practice Address - Street 1:165 SCOTT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-8847
Practice Address - Country:US
Practice Address - Phone:304-554-0400
Practice Address - Fax:304-554-0404
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD436112207N00000X, 207NS0135X
WV20946207N00000X, 207ND0101X, 207NS0135X
OH90420207N00000X
OH90429207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1810688000Medicaid
WV4216662OtherMEDICARE ID - TYPE UNSPECIFIED
PA145439Medicare PIN
WV4216662OtherMEDICARE ID - TYPE UNSPECIFIED