Provider Demographics
NPI:1265489926
Name:COWAP, CHARLES RICHARDSON (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARDSON
Last Name:COWAP
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 1:16616 ALDERSYDE DR
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14519 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4316
Practice Address - Country:US
Practice Address - Phone:216-521-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081096C207P00000X
OH35081096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000380937OtherANTHEM BC/BS
OH2373239Medicaid
OH341542312098OtherCARESOURCE
OH378646OtherWELLCARE
OH378646OtherWELLCARE
OHH78062Medicare UPIN