Provider Demographics
NPI:1053365346
Name:CHARLES, DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9099 E LANSING RD
Mailing Address - Street 2:STEA
Mailing Address - City:DURAND
Mailing Address - State:MI
Mailing Address - Zip Code:48429-1083
Mailing Address - Country:US
Mailing Address - Phone:989-288-2651
Mailing Address - Fax:
Practice Address - Street 1:9099 E LANSING RD
Practice Address - Street 2:STEA
Practice Address - City:DURAND
Practice Address - State:MI
Practice Address - Zip Code:48429-1083
Practice Address - Country:US
Practice Address - Phone:989-288-2651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114732575Medicaid
MI114732575Medicaid