=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871524355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES CHA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 02/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 MAIN ST FL 3
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-576-6141
-----------------------------------------------------
Fax | 203-581-6587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 MAIN ST FL 3
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-576-6141
-----------------------------------------------------
Fax | 203-581-6587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086X0206X
-----------------------------------------------------
Taxonomy Name | Surgical Oncology Physician
-----------------------------------------------------
License Number | 041377
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------