Provider Demographics
NPI:1699970830
Name:GILLESPIE, CHARLES P (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:GILLESPIE
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 1:2849 CRATER LAKE LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3488
Mailing Address - Country:US
Mailing Address - Phone:520-260-3478
Mailing Address - Fax:
Practice Address - Street 1:2849 CRATER LAKE LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3488
Practice Address - Country:US
Practice Address - Phone:520-260-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40833207P00000X
VT042.0012577207P00000X
CO48971207P00000X
NMMD2015-0100207P00000X
NE27906207PP0204X
CO0048971208000000X
NV16455207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ76686OtherRESIDENT PG PERMIT