Basic Information
| Provider Information | |||||||||
| NPI: | 1942207220 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WHITAKER | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | HARTFORD HOSPITAL PROFESSIONAL SERVICES | ||||||||
| Address2: | PO BOX 40,000 DEPT 634 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061510001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605457602 | ||||||||
| FaxNumber: | 8605457601 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 SEYMOUR ST | ||||||||
| Address2: | HARTFORD HOSPITAL NEUROLOGY DEPT | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061028000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605453621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 034387 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 001343871 | 05 | CT | MEDICAID |