Provider Demographics
NPI:1104939099
Name:CHARLES J ASWELL III MD A PROF MEDICAL CORP
Entity type:Organization
Organization Name:CHARLES J ASWELL III MD A PROF MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:ASWELL
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:337-363-7474
Mailing Address - Street 1:503 JACK MILLER ROAD
Mailing Address - Street 2:STE A
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586
Mailing Address - Country:US
Mailing Address - Phone:337-363-7474
Mailing Address - Fax:337-363-1197
Practice Address - Street 1:503 JACK MILLER ROAD
Practice Address - Street 2:STE A
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586
Practice Address - Country:US
Practice Address - Phone:337-363-7474
Practice Address - Fax:337-363-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1104939099OtherORGANIZATION NPI
1801842141OtherINDIVIDUAL NPI
LA1188531Medicaid
LA50313CT35Medicare ID - Type Unspecified
1801842141OtherINDIVIDUAL NPI