Provider Demographics
NPI:1598060907
Name:EKANEM, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:EKANEM
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 1:9 HILLDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117
Mailing Address - Country:US
Mailing Address - Phone:860-597-9371
Mailing Address - Fax:
Practice Address - Street 1:96 SILVER LN APT B12
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1007
Practice Address - Country:US
Practice Address - Phone:860-597-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ0000000207R00000X
CT50779208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine