Healthcare Provider Details

I. General information

NPI: 1912563594
Provider Name (Legal Business Name): MR. CHARLES MITCHELL SHOFNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

705 RILEY HOSPITAL DR RM 5837
INDIANAPOLIS IN
46202-5109
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0000
  • Fax:
Mailing address:
  • Phone: 317-948-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1912563594
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1912563594
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: