Provider Demographics
NPI:1699971960
Name:WEISE, CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:WEISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2343
Mailing Address - Country:US
Mailing Address - Phone:304-925-2159
Mailing Address - Fax:
Practice Address - Street 1:5600 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2343
Practice Address - Country:US
Practice Address - Phone:304-925-2159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV083832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0116671000Medicaid
WVWE6037041Medicare PIN