Provider Demographics
NPI:1851348312
Name:WASSON, CHARLES M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:WASSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5029 HICKORY POINTE DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1516
Mailing Address - Country:US
Mailing Address - Phone:248-681-6007
Mailing Address - Fax:
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:NOMC EMERCENCY CENTER
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7440
Practice Address - Fax:248-857-6992
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301406119207P00000X
NY285836207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104494778Medicaid
MIF31968Medicare UPIN
MION57910011Medicare ID - Type Unspecified