Provider Demographics
NPI:1205895208
Name:LAWLESS, CHARLES PITTMAN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:PITTMAN
Last Name:LAWLESS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1777 EAST CLARK STEET
Mailing Address - Street 2:SUITE 310
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3357
Mailing Address - Country:US
Mailing Address - Phone:208-232-4133
Mailing Address - Fax:208-232-4133
Practice Address - Street 1:1777 EAST CLARK STEET
Practice Address - Street 2:SUITE 310
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3357
Practice Address - Country:US
Practice Address - Phone:208-232-4133
Practice Address - Fax:208-232-4133
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM3434207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005308OtherREGENCE BLUE SHIELD
ID07302OtherBLUE CROSS
ID000010005308OtherREGENCE BLUE SHIELD
B63305Medicare UPIN