Healthcare Provider Details

I. General information

NPI: 1861482986
Provider Name (Legal Business Name): CHARLES WILES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST DK MILLER BUILDING MILLER BLDG.
BUFFALO NY
14215-3021
US

IV. Provider business mailing address

462 GRIDER ST DK MILLER BUILDING
BUFFALO NY
14215-3021
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-5103
  • Fax: 716-898-3194
Mailing address:
  • Phone: 716-898-5186
  • Fax: 716-898-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberD0024285
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: