Provider Demographics
NPI:1093753949
Name:WASSERMAN, CHARLES M (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:WASSERMAN
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 1:7500 CENTRAL AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2431
Mailing Address - Country:US
Mailing Address - Phone:215-742-0712
Mailing Address - Fax:215-742-5218
Practice Address - Street 1:7500 CENTRAL AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2431
Practice Address - Country:US
Practice Address - Phone:215-742-0712
Practice Address - Fax:215-742-5218
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006559L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4571206OtherAETNA PPO
PA0015583070022Medicaid
PA0470055OtherCIGNA HMO/PPO
PA10938435OtherCAQH ID#
PA469591OtherAETNA HMO
PA080134444OtherRRM
PA694010OtherHIGHMARK BLUE SHIELD
PA469591OtherAETNA HMO
PA694010OtherHIGHMARK BLUE SHIELD
PA0294553000OtherIBC - PC/KHPE
PA33022-OS006559LOtherHEALTH PARTNERS
PA080134444OtherRRM
PA0528982000OtherAMERIHEALTH/INTERCOUNTY
PA10938435OtherCAQH ID#