Provider Demographics
NPI:1053387456
Name:LAIS, CHARLES WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:LAIS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:530 3RD ST NW
Practice Address - Street 2:MAIL STOP 39400A
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1445
Practice Address - Country:US
Practice Address - Phone:763-712-6000
Practice Address - Fax:763-712-6591
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN29597207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75475Medicare UPIN