Provider Demographics
NPI:1700879830
Name:MCCORMICK, CHARLES OWEN III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:OWEN
Last Name:MCCORMICK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30 N EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8895
Mailing Address - Country:US
Mailing Address - Phone:317-881-3937
Mailing Address - Fax:317-887-4008
Practice Address - Street 1:30 N EMERSON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8895
Practice Address - Country:US
Practice Address - Phone:317-881-3937
Practice Address - Fax:317-887-4008
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026314A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000011606OtherMPLAN
IN352129520OtherUNITED MINE WORKERS
IN000000214798OtherBCBS
IN180044022OtherRAILROAD MEDICARE
IN100154690Medicaid
IN000000011606OtherSENIOR SMART CHOICE
IN154727OtherCOLE VISION
INAETNAOtherAETNA
IN100154690Medicaid
IN180044022OtherRAILROAD MEDICARE