Provider Demographics
NPI:1710915830
Name:NIESEN, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:NIESEN
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 1:960 E GREEN ST
Mailing Address - Street 2:SUITE L11
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2412
Mailing Address - Country:US
Mailing Address - Phone:626-599-7600
Mailing Address - Fax:626-599-7601
Practice Address - Street 1:960 E GREEN ST
Practice Address - Street 2:SUITE L11
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2412
Practice Address - Country:US
Practice Address - Phone:626-599-7600
Practice Address - Fax:626-599-7601
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF73927Medicare UPIN