Provider Demographics
NPI:1891781852
Name:MYERS, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:MYERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:303 S MAIN ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2159
Mailing Address - Country:US
Mailing Address - Phone:574-255-3108
Mailing Address - Fax:574-255-3100
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:SUITE 108
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2159
Practice Address - Country:US
Practice Address - Phone:574-255-3108
Practice Address - Fax:574-255-3100
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01025417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100222130Medicaid
INE05301Medicare UPIN
INMY728900Medicare PIN