Provider Demographics
NPI:1649250341
Name:VANCE, CHARLES III (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:VANCE
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 LYNN AVE
Practice Address - Street 2:
Practice Address - City:HAMLIN
Practice Address - State:WV
Practice Address - Zip Code:25523-1138
Practice Address - Country:US
Practice Address - Phone:304-824-5806
Practice Address - Fax:304-824-5804
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000000229369OtherANTHEM
WV080188645OtherRR MEDICARE
WV001709560OtherMT. STATE
WV0049874000Medicaid
WV000000229369OtherANTHEM
WV2022763Medicare PIN