Provider Demographics
NPI:1902073422
Name:ILAWAN, CHARLIE P
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:P
Last Name:ILAWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3323
Mailing Address - Country:US
Mailing Address - Phone:985-735-7372
Mailing Address - Fax:985-732-5944
Practice Address - Street 1:400 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3323
Practice Address - Country:US
Practice Address - Phone:985-735-7372
Practice Address - Fax:985-732-5944
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4361122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1843610Medicaid
PA971021OtherUNITED CONCORDIA
LAA2370OtherBLUE CROSS BLUE SHIELD OF LA
MS00660199Medicaid