Healthcare Provider Details

I. General information

NPI: 1598789356
Provider Name (Legal Business Name): CHARLES S MERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 S LAMAR ST APT 705
DALLAS TX
75215-6839
US

IV. Provider business mailing address

1409 S LAMAR ST APT 705
DALLAS TX
75215-6839
US

V. Phone/Fax

Practice location:
  • Phone: 561-723-4235
  • Fax: 972-913-4371
Mailing address:
  • Phone: 561-723-4235
  • Fax: 972-913-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number56773
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number56773
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA47852
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA47852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: