Provider Demographics
NPI:1154503498
Name:FRACCHIA, CHARLES A JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:FRACCHIA
Suffix:JR
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 1:784 WILLBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3719
Mailing Address - Country:US
Mailing Address - Phone:650-685-7417
Mailing Address - Fax:
Practice Address - Street 1:784 WILLBOROUGH RD
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3719
Practice Address - Country:US
Practice Address - Phone:650-685-7417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40084208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice