Provider Demographics
NPI:1366443533
Name:KERBER, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:KERBER
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 1:4444 TOPA TOPA DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7160
Mailing Address - Country:US
Mailing Address - Phone:760-598-8058
Mailing Address - Fax:760-598-8078
Practice Address - Street 1:4444 TOPA TOPA DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7160
Practice Address - Country:US
Practice Address - Phone:760-598-8058
Practice Address - Fax:760-598-8078
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-03-11
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAC307352085N0700X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C307351Medicaid
CAOOC307350OtherBLUE SHIELD
CAHC30735Medicare PIN
CA00C307351Medicaid