Provider Demographics
NPI:1992133789
Name:CHARLES, GINA LAVERNE (DO)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:LAVERNE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 E CHOCOLATE AVE
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-1325
Mailing Address - Country:US
Mailing Address - Phone:717-533-4935
Mailing Address - Fax:
Practice Address - Street 1:565 E CHOCOLATE AVE
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033
Practice Address - Country:US
Practice Address - Phone:717-533-4935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT015547207Q00000X
PAOS017893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA531904F6KMedicare PIN