Provider Demographics
NPI:1356348213
Name:JARBOE, CHARLES D (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:JARBOE
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 1:912 WALLACE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-2405
Mailing Address - Country:US
Mailing Address - Phone:270-230-8200
Mailing Address - Fax:270-230-0882
Practice Address - Street 1:912 WALLACE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2404
Practice Address - Country:US
Practice Address - Phone:270-230-8200
Practice Address - Fax:270-230-0882
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2007-07-09
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
KY22717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000222830OtherANTHEM PIN #
10804168OtherCAQH UNIVERSAL CREDENTIAL
KY320012117OtherTAX ID
18D0999959OtherCLIA
KY64227176Medicaid
KY64227176Medicaid
KYC69145Medicare UPIN