Provider Demographics
NPI:1316056013
Name:BERTUCH, CHARLES JOSEPH JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:BERTUCH
Suffix:JR
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 1:1120 E ELIZABETH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524
Mailing Address - Country:US
Mailing Address - Phone:970-493-9193
Mailing Address - Fax:970-639-4475
Practice Address - Street 1:1120 E ELIZABETH STREET
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-493-9193
Practice Address - Fax:970-639-4475
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY99421-1174400000X
CODR.00522612083A0300X
NY099426202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00553493Medicaid
NY18111OtherMVP HEALTHPLAN
0000CM0523OtherRAILROAD MEDICARE
NY000405418002OtherBSH NE NY
NY00553493Medicaid
NY00553493Medicaid
NY18111OtherMVP HEALTHPLAN