Provider Demographics
NPI:1528243300
Name:WARD, CHARISSE JANET (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:JANET
Last Name:WARD
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S GULPH RD, ATN :IPM CREDENTIALING
Mailing Address - Street 2:ATN :IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:580-297-5166
Mailing Address - Fax:580-237-1340
Practice Address - Street 1:1051 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2951
Practice Address - Country:US
Practice Address - Phone:985-641-7577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-29
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA306659207RC0000X, 207RI0011X
TXQ9078207RC0000X
OK38234207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200985520AMedicaid
WI100233521Medicaid
OK1Q0274OtherPTAN