Provider Demographics
NPI:1174507289
Name:HANDORF, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:HANDORF
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 1:1211 UNION AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6638
Mailing Address - Country:US
Mailing Address - Phone:901-725-7551
Mailing Address - Fax:901-725-9721
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:901-725-7551
Practice Address - Fax:901-725-9721
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN010717207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3040832Medicaid
TNB00253Medicare UPIN
TN3040832Medicaid