Provider Demographics
NPI:1972502920
Name:MASSERMAN, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:MASSERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1064 E MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4898
Mailing Address - Country:US
Mailing Address - Phone:203-634-3636
Mailing Address - Fax:203-634-1972
Practice Address - Street 1:1064 E MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4898
Practice Address - Country:US
Practice Address - Phone:203-634-3636
Practice Address - Fax:203-634-1972
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT027029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001270298Medicaid
CT001270298Medicaid
CTB77200Medicare UPIN