Healthcare Provider Details

I. General information

NPI: 1447205448
Provider Name (Legal Business Name): CHARLES HIGGS-COULTHARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 406
MISHAWAKA IN
46545-1468
US

IV. Provider business mailing address

707 E CEDAR ST STE 200
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6580
  • Fax: 574-335-0796
Mailing address:
  • Phone: 574-335-8700
  • Fax: 574-335-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01042925
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: