Provider Demographics
NPI:1154486348
Name:PREWITT, CHARLES D (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:D
Last Name:PREWITT
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 1:1901 S UNION AVE
Mailing Address - Street 2:STE B3001
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1702
Mailing Address - Country:US
Mailing Address - Phone:253-272-7614
Mailing Address - Fax:253-383-1381
Practice Address - Street 1:1901 S UNION AVE
Practice Address - Street 2:STE B3001
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1702
Practice Address - Country:US
Practice Address - Phone:253-272-7614
Practice Address - Fax:253-383-1381
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00009048207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1693100Medicaid
WA1693100Medicaid
A08570Medicare UPIN