Provider Demographics
NPI:1609499193
Name:CHARLES, FRED HENRY DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:HENRY DANIEL
Last Name:CHARLES
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 1:25326 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1784
Mailing Address - Country:US
Mailing Address - Phone:203-820-5977
Mailing Address - Fax:
Practice Address - Street 1:6001 W OUTER DR STE 114
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2626
Practice Address - Country:US
Practice Address - Phone:313-966-9444
Practice Address - Fax:313-966-9418
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301507592207R00000X
MI4351047136390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program