Provider Demographics
NPI:1205819596
Name:CALLERY, CHARLES DAWSON (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAWSON
Last Name:CALLERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15725 POMERADO RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2068
Mailing Address - Country:US
Mailing Address - Phone:858-675-0883
Mailing Address - Fax:858-675-0549
Practice Address - Street 1:15725 POMERADO RD
Practice Address - Street 2:SUITE 206
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2068
Practice Address - Country:US
Practice Address - Phone:858-675-0883
Practice Address - Fax:858-675-0549
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG33450208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G335401Medicaid
CAG33540OtherSTATE LIC NUMBER
CAA45584Medicare UPIN