Provider Demographics
NPI:1376642355
Name:WANICH, CHARLES K (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:K
Last Name:WANICH
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 1:245 S COURTENAY PARKWAY
Mailing Address - Street 2:BLDG B
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-453-5326
Mailing Address - Fax:321-452-8507
Practice Address - Street 1:245 S COURTENAY PARKWAY
Practice Address - Street 2:BLDG B
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-453-5326
Practice Address - Fax:321-452-8507
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME36933207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
110202974OtherRR MEDICARE
FL039647800Medicaid
2168973OtherAETNA
D54715Medicare UPIN
41172Medicare ID - Type Unspecified