Provider Demographics
NPI:1891766176
Name:MALIS, CHARLES D (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:MALIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:56 WINTHROP ST
Mailing Address - Street 2:UNIT 1 THE CONCORD CLINIC
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2076
Mailing Address - Country:US
Mailing Address - Phone:978-369-2266
Mailing Address - Fax:978-369-5205
Practice Address - Street 1:107 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649
Practice Address - Country:US
Practice Address - Phone:508-477-7090
Practice Address - Fax:508-477-3090
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-06-15
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Provider Licenses
StateLicense IDTaxonomies
MA58602207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3024741Medicaid
MA3024741Medicaid
B98109Medicare UPIN