Provider Demographics
NPI:1164480133
Name:ANDERSON, CHARLES W (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 CRUZ ALTA
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6279
Mailing Address - Country:US
Mailing Address - Phone:505-758-8651
Mailing Address - Fax:505-758-8711
Practice Address - Street 1:123 CRUZ ALTA
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6279
Practice Address - Country:US
Practice Address - Phone:505-758-8651
Practice Address - Fax:505-758-7811
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-08-31
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-31
Provider Licenses
StateLicense IDTaxonomies
NM64-23208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1305Medicaid
NM1305Medicaid