Provider Demographics
NPI:1689801441
Name:FORD, CHARLES RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:FORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4742 BLACK SWAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216
Mailing Address - Country:US
Mailing Address - Phone:913-268-0265
Mailing Address - Fax:913-768-8210
Practice Address - Street 1:4742 BLACK SWAN DRIVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216
Practice Address - Country:US
Practice Address - Phone:913-268-0265
Practice Address - Fax:913-768-8210
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-13088207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS04-13088OtherKANSAS STATE BOARD OF HEALING ARTS