Provider Demographics
NPI:1710128541
Name:CHARLESTON DIABETES & ENDOCRINE CONSULTANTS, PLLC
Entity Type:Organization
Organization Name:CHARLESTON DIABETES & ENDOCRINE CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRASUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-720-4422
Mailing Address - Street 1:3100 MACCORKLE AVE
Mailing Address - Street 2:SUITE 810
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1223
Mailing Address - Country:US
Mailing Address - Phone:304-720-4422
Mailing Address - Fax:304-720-4421
Practice Address - Street 1:3100 MACCORKLE AVE
Practice Address - Street 2:SUITE 810
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-720-4422
Practice Address - Fax:304-720-4421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21072207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014496Medicaid
WVCH9382491Medicare PIN