Provider Demographics
NPI:1154360378
Name:CHARDOUL, EUGENE N (MD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:N
Last Name:CHARDOUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:810-820-8121
Mailing Address - Fax:810-820-8335
Practice Address - Street 1:3499 S LINDEN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3022
Practice Address - Country:US
Practice Address - Phone:810-820-8121
Practice Address - Fax:810-820-8335
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301023744207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1158646Medicaid
MI0B50683OtherBCBS
MIEC023744OtherSTATE LIC #
MI0M01780001Medicare ID - Type Unspecified
MI1158646Medicaid