Provider Demographics
NPI:1003964784
Name:PATTAN, CHARLES R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:PATTAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:833-724-8326
Practice Address - Fax:260-266-8941
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301051609207Q00000X, 207V00000X
IN01082842A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2989963Medicaid
MI2989963Medicaid