Provider Demographics
NPI:1336168830
Name:HADDOCK, CHARLES HARRY (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HARRY
Last Name:HADDOCK
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 1:940 PEPPER AVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-6307
Mailing Address - Country:US
Mailing Address - Phone:715-421-4344
Mailing Address - Fax:715-421-4341
Practice Address - Street 1:940 PEPPER AVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6307
Practice Address - Country:US
Practice Address - Phone:715-421-4344
Practice Address - Fax:715-421-4341
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI414-025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391318842E00OtherBLUE CROSS BLUE SHIELD
WI39-1318842OtherWEA TRUST
WI137751120246OtherHUMANA
WI43225600Medicaid
WIT62091Medicare UPIN
WI137751120246OtherHUMANA
WI000084490Medicare ID - Type Unspecified