Healthcare Provider Details

I. General information

NPI: 1184658148
Provider Name (Legal Business Name): CHARLES MICHAEL WAX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COLGATE DR SUITE 104
FOREST HILL MD
21050-2624
US

IV. Provider business mailing address

1617 N BEND RD
JARRETTSVILLE MD
21084-1329
US

V. Phone/Fax

Practice location:
  • Phone: 410-838-1051
  • Fax: 410-838-5325
Mailing address:
  • Phone: 410-838-1051
  • Fax: 410-838-5325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberD0024542
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: