Provider Demographics
NPI:1174638068
Name:HOOPER, CHARLES IVERSON (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:IVERSON
Last Name:HOOPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1860 HOWE AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1098
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:916-256-2214
Practice Address - Street 1:6339 MACK RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4655
Practice Address - Country:US
Practice Address - Phone:916-454-2345
Practice Address - Fax:916-457-2667
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5310207Q00000X
UT67358218020207Q00000X
UT67358218019207Q00000X
UT6735821-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1982871828Medicaid
UT200785958001Medicaid
UT200785958001Medicaid