Healthcare Provider Details

I. General information

NPI: 1629070552
Provider Name (Legal Business Name): CHARLES L. DEMARIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RIDGE ROAD SUITE 1
NEWTON FALLS OH
44444
US

IV. Provider business mailing address

340 RIDGE ROAD SUITE 1
NEWTON FALLS OH
44444
US

V. Phone/Fax

Practice location:
  • Phone: 330-872-0330
  • Fax: 330-872-7664
Mailing address:
  • Phone: 330-872-0330
  • Fax: 330-872-7664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35050888
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.050888
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35050888D
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: