Provider Demographics
NPI:1265431845
Name:SUGARMAN, CHARLES J (DPM)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:SUGARMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHAMBER CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1686
Mailing Address - Country:US
Mailing Address - Phone:859-441-4334
Mailing Address - Fax:859-441-3698
Practice Address - Street 1:525 ALEXANDRIA PIKE
Practice Address - Street 2:SUITE 230
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3290
Practice Address - Country:US
Practice Address - Phone:859-441-4334
Practice Address - Fax:859-441-3698
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00170213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY27-00336OtherUHC
KY90260191Medicaid
KY4491387OtherAETNA
KY80001704Medicaid
KY000000033161OtherANTHEM
KY90260191Medicaid
KY2013801Medicare PIN
KY4491387OtherAETNA
KY80001704Medicaid