Provider Demographics
NPI:1124006465
Name:DWAN, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:DWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 GULL RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1632
Mailing Address - Country:US
Mailing Address - Phone:269-903-2835
Mailing Address - Fax:269-903-2838
Practice Address - Street 1:1634 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1632
Practice Address - Country:US
Practice Address - Phone:269-903-2835
Practice Address - Fax:269-903-2838
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101025762207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5056607Medicare PIN
B93364Medicare UPIN