Provider Demographics
NPI:1659846897
Name:MENSAH, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MENSAH
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 1:1703 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-3040
Mailing Address - Country:US
Mailing Address - Phone:240-421-6567
Mailing Address - Fax:
Practice Address - Street 1:14203 WOLF CREEK PL
Practice Address - Street 2:
Practice Address - City:ASPEN HILL
Practice Address - State:MD
Practice Address - Zip Code:20906-6196
Practice Address - Country:US
Practice Address - Phone:240-421-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM-520-115-161-711172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3177OtherWMATC