Provider Demographics
NPI:1689683492
Name:CONKLIN, CHARLES ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:CONKLIN
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 1:323 MARION AVENUE NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646
Mailing Address - Country:US
Mailing Address - Phone:330-832-8800
Mailing Address - Fax:330-832-3142
Practice Address - Street 1:323 MARION AVENUE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646
Practice Address - Country:US
Practice Address - Phone:330-832-8800
Practice Address - Fax:330-832-3142
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.002344208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0303522Medicaid
OH0303522Medicaid
CO7266711Medicare ID - Type Unspecified