Provider Demographics
NPI:1932103736
Name:MILLSAP, CHARLES MARK (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARK
Last Name:MILLSAP
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 1:2845 FARRELL CRESCENT
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303
Mailing Address - Country:US
Mailing Address - Phone:270-926-3297
Mailing Address - Fax:270-926-7325
Practice Address - Street 1:2845 FARRELL CRESCENT
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-926-3297
Practice Address - Fax:270-926-7325
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30334207W00000X
IN01043469A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000273547OtherANTHEM
180018982OtherRAILROAD MEDICARE
IN100361620Medicaid
KY64303340Medicaid
KY64303340Medicaid
E59109Medicare UPIN
IN100361620Medicaid
180018982OtherRAILROAD MEDICARE
KY0207105Medicare PIN