Provider Demographics
NPI:1992763353
Name:CONNOR, CHARLES DOBBIN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOBBIN
Last Name:CONNOR
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 1:22 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5669
Mailing Address - Country:US
Mailing Address - Phone:618-288-0998
Mailing Address - Fax:618-288-9934
Practice Address - Street 1:22 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5669
Practice Address - Country:US
Practice Address - Phone:618-288-0998
Practice Address - Fax:618-288-9934
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4233211OtherAETNA
IL06032047OtherBLUE CROSS/BLUE SHIELD
IL127279OtherGHP
IL2119084OtherAETNA MANAGED CARE
IL5226143OtherCCN
IL1736541OtherFIRST HEALTH
IL0300073OtherUNITEDHEATHCARE
IL294801OtherHEALTHLINK
IL2644579OtherCIGNA
ILG37507OtherMERCY
G37507Medicare UPIN
IL294801OtherHEALTHLINK