Healthcare Provider Details

I. General information

NPI: 1639231087
Provider Name (Legal Business Name): DAVID CHARLES CARLISLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SCOTT AVE SUITE 100
MORGANTOWN WV
26508-8847
US

IV. Provider business mailing address

125 N 6TH ST
CLARKSBURG WV
26301-2665
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-0400
  • Fax: 304-554-0404
Mailing address:
  • Phone: 304-624-7200
  • Fax: 304-554-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD436112
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD436112
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20946
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number90420
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number90429
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number90429
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number20946
License Number StateWV
# 8
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number20946
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: