Provider Demographics
NPI:1669452090
Name:MARESH, CHARLES G (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:MARESH
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 1:51 WILLIAM B GRAHAM CT
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-3852
Mailing Address - Country:US
Mailing Address - Phone:804-435-0575
Mailing Address - Fax:804-435-9017
Practice Address - Street 1:51 WILLIAM B GRAHAM CT
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-3852
Practice Address - Country:US
Practice Address - Phone:804-435-0575
Practice Address - Fax:804-435-9017
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010139996Medicaid
1669452090OtherCMS