Provider Demographics
NPI:1881740587
Name:CHARLES, VIJAYAN (MD)
Entity type:Individual
Prefix:
First Name:VIJAYAN
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7237 HANOVER PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3602
Mailing Address - Country:US
Mailing Address - Phone:301-982-4892
Mailing Address - Fax:301-982-5813
Practice Address - Street 1:7237 HANOVER PKWY STE B
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3602
Practice Address - Country:US
Practice Address - Phone:301-982-4892
Practice Address - Fax:301-982-5813
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014192208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD017051800Medicaid
DC175261YADGMedicare PIN
MD017051800Medicaid