=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144222480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES DEMIRJIAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2005
-----------------------------------------------------
Last Update Date | 10/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7034 CORPORATE WAY
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-4237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-298-3800
-----------------------------------------------------
Fax | 937-296-0272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3732 BLOSSOM HEATH RD
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45419-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-298-3800
-----------------------------------------------------
Fax | 937-296-0272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 35048624D
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------