Provider Demographics
NPI:1700887262
Name:COATS, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:COATS
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 1:1330 N COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5526
Mailing Address - Country:US
Mailing Address - Phone:260-447-8982
Mailing Address - Fax:260-447-4483
Practice Address - Street 1:1330 N COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5526
Practice Address - Country:US
Practice Address - Phone:260-447-8982
Practice Address - Fax:260-447-4483
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053073A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200231180Medicaid
INH27551Medicare UPIN
IN192580AMedicare ID - Type Unspecified