Provider Demographics
NPI:1205819034
Name:HARTMAN, CHARLES ROBERT JR (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:HARTMAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10890 VETERANS MEMORIAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1475
Mailing Address - Country:US
Mailing Address - Phone:636-561-6801
Mailing Address - Fax:636-625-1601
Practice Address - Street 1:300 MEDICAL PLZ STE 310
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1484
Practice Address - Country:US
Practice Address - Phone:636-625-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5P00208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO248492001Medicaid
MO005010679Medicare ID - Type Unspecified
MO248492001Medicaid