Provider Demographics
NPI:1750367983
Name:HUMPHRIES, CHARLES T (M D)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 E HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-5602
Mailing Address - Country:US
Mailing Address - Phone:337-263-4958
Mailing Address - Fax:
Practice Address - Street 1:6850 E HAVEN CT
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-5602
Practice Address - Country:US
Practice Address - Phone:337-263-4958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024656207Q00000X
KY46156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1571482Medicaid
LAH21802Medicare UPIN
LA1571482Medicaid
LA5H518Medicare ID - Type Unspecified