Provider Demographics
NPI:1770711145
Name:CHARLTON, JANEL L (MD)
Entity type:Individual
Prefix:
First Name:JANEL
Middle Name:L
Last Name:CHARLTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANEL
Other - Middle Name:L
Other - Last Name:DAUFENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:714 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1035
Practice Address - Country:US
Practice Address - Phone:574-647-7477
Practice Address - Fax:574-647-3655
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070363A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201073620Medicaid
IN000000776952OtherBCBS BMG E BLAIR WARNER
IN000000776952OtherBCBS BMG E BLAIR WARNER
IN000000789423OtherBCBS CENTENNIEAL HELATH CENTER
IN201073620Medicaid
IN000000878088OtherBCBS BMG SPORTS MEDICINE
IN000000878088OtherBCBS BMG SPORTS MEDICINE
IN201073620Medicaid
IN000000789423OtherBCBS CENTENNIEAL HELATH CENTER
INM400074504Medicare PIN