Provider Demographics
NPI:1790043446
Name:WALCOTT, CHARLES CHRISTOPHER (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CHRISTOPHER
Last Name:WALCOTT
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-763-6075
Mailing Address - Fax:607-763-5234
Practice Address - Street 1:40 ARCH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2102
Practice Address - Country:US
Practice Address - Phone:607-763-6075
Practice Address - Fax:607-763-5234
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT054219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program