Healthcare Provider Details

I. General information

NPI: 1487656443
Provider Name (Legal Business Name): CHARLES WILLIAM BARTHOLOME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 W ROYALE DR
MUNCIE IN
47304-2243
US

IV. Provider business mailing address

1808 W ROYALE DR
MUNCIE IN
47304-2243
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-8188
  • Fax: 765-282-7242
Mailing address:
  • Phone: 765-288-8188
  • Fax: 765-282-7242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number100348140
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number100348140
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number100348140
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: