Provider Demographics
NPI:1205863552
Name:DOLLBAUM, CHARLES M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:DOLLBAUM
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 1:1635 DIVISADERO ST
Mailing Address - Street 2:SUITE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:1600 DIVISADERO ST FL 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3010
Practice Address - Country:US
Practice Address - Phone:415-353-7070
Practice Address - Fax:415-353-7021
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48211207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G482110Medicaid
CAA50973Medicare UPIN
CA00G482110Medicaid