Provider Demographics
NPI:1396712683
Name:DAVID, CHARLES SR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:DAVID
Suffix:SR
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 1:3501 S CRISSEY RD
Mailing Address - Street 2:
Mailing Address - City:MONCLOVA
Mailing Address - State:OH
Mailing Address - Zip Code:43542-9766
Mailing Address - Country:US
Mailing Address - Phone:419-350-5652
Mailing Address - Fax:419-861-8335
Practice Address - Street 1:725 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1702
Practice Address - Country:US
Practice Address - Phone:419-335-2015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-05
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057726207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0725666Medicaid
MI5214037Medicaid
OH810547599071OtherCARESOURCE
OH000000522471OtherANTHEM BCBS
OHDA4210803Medicare PIN
OH0725666Medicaid