Provider Demographics
NPI:1598839433
Name:MIRON, CHARLES DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:MIRON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 TIMBERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-4422
Mailing Address - Country:US
Mailing Address - Phone:410-653-3777
Mailing Address - Fax:
Practice Address - Street 1:3200 TIMBERFIELD LN
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-4422
Practice Address - Country:US
Practice Address - Phone:410-653-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD34253001OtherBLUE CROSS NUMBER
MDG599OtherBLUE CROSSBLUE SHIELD
MDR778OtherBLUE CHOICE NUMBER
MD34253001OtherBLUE CROSS NUMBER