Provider Demographics
NPI:1376104059
Name:EARLEY, CHARLES DANIEL LEO (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DANIEL LEO
Last Name:EARLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:617-414-7399
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVE
Practice Address - Street 2:CROSSTOWN 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-5189
Practice Address - Country:US
Practice Address - Phone:617-414-7399
Practice Address - Fax:617-414-4676
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT217604207R00000X
MA1017742207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine