Provider Demographics
NPI:1114362175
Name:BLACKSHEAR, CHARLES PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PHILIP
Last Name:BLACKSHEAR
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 1:1389 JEFFERSON ST UNIT A507
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4949 STEVENS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-6661
Practice Address - Country:US
Practice Address - Phone:408-260-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-05
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program