Provider Demographics
NPI:1699778613
Name:PESSON, CHARLES MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:PESSON
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 1:245 FLEMINGSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1015
Mailing Address - Country:US
Mailing Address - Phone:606-780-5500
Mailing Address - Fax:606-783-7281
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1015
Practice Address - Country:US
Practice Address - Phone:606-780-5500
Practice Address - Fax:606-783-7281
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53502207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100658660Medicaid
KY53502OtherKY MEDICAL LICENSE
GA00503346AMedicaid
20BBCZHMedicare PIN