Provider Demographics
NPI:1023040599
Name:KODIMER, CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:KODIMER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41934 MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2714
Mailing Address - Country:US
Mailing Address - Phone:562-861-6180
Mailing Address - Fax:951-694-0553
Practice Address - Street 1:10927 DOWNEY AVE STE C
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3739
Practice Address - Country:US
Practice Address - Phone:562-861-6180
Practice Address - Fax:951-694-0553
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6629103TC0700X, 103G00000X
CAMFC 6318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP6629AMedicare ID - Type Unspecified
CACP6629Medicare ID - Type Unspecified
CP6629AMedicare ID - Type Unspecified