Healthcare Provider Details

I. General information

NPI: 1316948789
Provider Name (Legal Business Name): CHARLES FLOYD MOTLEY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6916 W JOHNSON RD
LA PORTE IN
46350-8247
US

IV. Provider business mailing address

6916 W JOHNSON RD
LA PORTE IN
46350-8247
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-7247
  • Fax: 219-879-8609
Mailing address:
  • Phone: 219-872-7247
  • Fax: 219-879-8609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01030248B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01030248A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: