Provider Demographics
NPI:1093825150
Name:GRUDEM, CHARLES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:GRUDEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SW 34TH AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-7456
Mailing Address - Country:US
Mailing Address - Phone:352-629-7011
Mailing Address - Fax:352-629-7924
Practice Address - Street 1:3200 SW 34TH AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7456
Practice Address - Country:US
Practice Address - Phone:352-629-7011
Practice Address - Fax:352-629-7924
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 61060208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
17875OtherBCBS
FL720000084OtherRAILROAD MEDICARE
FL17875ZMedicare PIN
17875OtherBCBS