Provider Demographics
NPI:1942207220
Name:WHITAKER, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WHITAKER
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 1:2150 CORBIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-2298
Mailing Address - Country:US
Mailing Address - Phone:860-612-6305
Mailing Address - Fax:860-612-6304
Practice Address - Street 1:2150 CORBIN AVE
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-2298
Practice Address - Country:US
Practice Address - Phone:860-612-6305
Practice Address - Fax:860-612-6304
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0343872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001343871Medicaid
CT001343871Medicaid
CT130000627Medicare PIN