Provider Demographics
NPI:1164401899
Name:HELLER, CHARMALIE G (MD)
Entity Type:Individual
Prefix:
First Name:CHARMALIE
Middle Name:G
Last Name:HELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARMALIE
Other - Middle Name:G
Other - Last Name:JAYASEKERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 GOVE ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1920
Mailing Address - Country:US
Mailing Address - Phone:617-569-5800
Mailing Address - Fax:617-568-4780
Practice Address - Street 1:10 GOVE ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1920
Practice Address - Country:US
Practice Address - Phone:617-569-5800
Practice Address - Fax:617-568-4780
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217764208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2016290Medicaid
MAA35459Medicare ID - Type Unspecified
MA2016290Medicaid