Provider Demographics
NPI:1629070552
Name:DEMARIO, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:DEMARIO
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 1:340 RIDGE ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEWTON FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44444
Mailing Address - Country:US
Mailing Address - Phone:330-872-0330
Mailing Address - Fax:330-872-7664
Practice Address - Street 1:340 RIDGE ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWTON FALLS
Practice Address - State:OH
Practice Address - Zip Code:44444
Practice Address - Country:US
Practice Address - Phone:330-872-0330
Practice Address - Fax:330-872-7664
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050888207V00000X
OH35.050888207Q00000X
OH35050888D207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000757681OtherANTHEM
OH341609341059OtherCARESOURCE
OH000000171147OtherUHC
OH000000757533OtherANTHEM
OH000000757696OtherANTHEM
OH000000757512OtherANTHEM
OH0564241Medicaid
OHC02792OtherUPIN
OH000000757512OtherANTHEM