Healthcare Provider Details

I. General information

NPI: 1700043155
Provider Name (Legal Business Name): DR. CHARLES WALTER DEBROSSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

8039 WASHINGTON VILLAGE DR STE 100
CENTERVILLE OH
45458-1877
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4200
  • Fax:
Mailing address:
  • Phone: 513-636-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.089171
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: