Provider Demographics
NPI:1194853770
Name:DESHAZER, CHARLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:
Last Name:DESHAZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:DESHAZER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-479-5541
Mailing Address - Fax:216-479-5554
Practice Address - Street 1:1001 LAKESIDE AVE E
Practice Address - Street 2:#1200
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1158
Practice Address - Country:US
Practice Address - Phone:216-479-5541
Practice Address - Fax:216-479-5554
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-088905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine