Provider Demographics
NPI:1396940326
Name:CHARLES, JEAN B (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:B
Last Name:CHARLES
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:PO BOX 365481
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-0009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-296-1828
Practice Address - Fax:617-296-5717
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA056584207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3071413Medicaid
MA3071413Medicaid
MAJ09810Medicare ID - Type Unspecified