Provider Demographics
NPI:1235159278
Name:WRESCHNER, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:WRESCHNER
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 1:21 WAINWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281-3030
Mailing Address - Country:US
Mailing Address - Phone:860-928-5726
Mailing Address - Fax:
Practice Address - Street 1:235 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1835
Practice Address - Country:US
Practice Address - Phone:860-928-0493
Practice Address - Fax:860-928-9255
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1175611Medicaid
010000636Medicare ID - Type Unspecified
CT1175611Medicaid