Provider Demographics
NPI:1225016009
Name:VERNON, CHARLES B (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:VERNON
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 1:1791 HIGHWAY 64 E
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-2112
Mailing Address - Country:US
Mailing Address - Phone:319-462-3571
Mailing Address - Fax:319-462-6043
Practice Address - Street 1:1791 HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-2112
Practice Address - Country:US
Practice Address - Phone:319-462-3571
Practice Address - Fax:319-462-6043
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24257207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA080116811OtherRR MEDICARE
IA3019570Medicaid
IA1225016009Medicaid
IA080116811OtherRR MEDICARE
IA3019570Medicaid