Provider Demographics
NPI:1396960282
Name:WAMBULWA, CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:WAMBULWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:WAMBULWA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:633 W RITTENHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:633 W RITTENHOUSE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-4325
Practice Address - Country:US
Practice Address - Phone:215-609-4413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT188442207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine