Provider Demographics
NPI:1215981519
Name:DUMONTIER, CHARLES C (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:DUMONTIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 WEST LINCOLN STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220
Mailing Address - Country:US
Mailing Address - Phone:618-235-0955
Mailing Address - Fax:618-235-9203
Practice Address - Street 1:180 SOUTH THIRD STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220
Practice Address - Country:US
Practice Address - Phone:618-235-0651
Practice Address - Fax:618-235-9722
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360668192085R0202X
MOR9A582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
L95013OtherMEDICARE PIN
141550OtherHEALTHLINK
IL36066819Medicaid
L95013OtherMEDICARE PIN
IL36066819Medicaid