Healthcare Provider Details

I. General information

NPI: 1720063142
Provider Name (Legal Business Name): CHARLES D ALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 GOVERNORS AVE
MEDFORD MA
02155-3017
US

IV. Provider business mailing address

49 GOVERNORS AVE
MEDFORD MA
02155-3017
US

V. Phone/Fax

Practice location:
  • Phone: 781-395-6122
  • Fax: 781-395-2595
Mailing address:
  • Phone: 781-395-6122
  • Fax: 781-395-2595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number40486
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: