Provider Demographics
NPI:1154479145
Name:MA, CHARLES C (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:MA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3102 E. HIGHLAND AVENUE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369
Mailing Address - Country:US
Mailing Address - Phone:909-425-7679
Mailing Address - Fax:909-425-6635
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7679
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA861352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A861350Medicaid
CA00A861350Medicaid