Provider Demographics
NPI:1316948789
Name:MOTLEY, CHARLES FLOYD JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:FLOYD
Last Name:MOTLEY
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 1:6916 W JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-8247
Mailing Address - Country:US
Mailing Address - Phone:219-872-7247
Mailing Address - Fax:219-879-8609
Practice Address - Street 1:6916 W JOHNSON RD
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-8247
Practice Address - Country:US
Practice Address - Phone:219-872-7247
Practice Address - Fax:219-879-8609
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030248A2084P0800X
IN01030248B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000316332OtherANTHEM BLUE CROSS
IN100163900AMedicaid
IN100163900AMedicaid
IN485990Medicare ID - Type Unspecified
000000316332OtherANTHEM BLUE CROSS