Provider Demographics
NPI:1669437828
Name:LALLIER, CHARLES WESLEY (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WESLEY
Last Name:LALLIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 FREEDOM LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704
Mailing Address - Country:US
Mailing Address - Phone:919-477-2202
Mailing Address - Fax:919-471-2270
Practice Address - Street 1:4022 FREEDOM LAKE DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704
Practice Address - Country:US
Practice Address - Phone:919-477-2202
Practice Address - Fax:919-471-2270
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28057208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC50624OtherBSBC STATE FEDERAL NC HEA
4221816OtherAETNA
269611OtherMAMSI ALLIANCE
1250106OtherUNITED HEALTHCARE
NC8950624Medicaid
50121OtherMEDCOST
8950624OtherCAROLINA ACCESS NC
4221816OtherAETNA