Provider Demographics
NPI:1417917840
Name:OLTORF, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:OLTORF
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 1:3313 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-2263
Mailing Address - Country:US
Mailing Address - Phone:512-391-9025
Mailing Address - Fax:
Practice Address - Street 1:3313 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-2263
Practice Address - Country:US
Practice Address - Phone:512-391-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5139208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX807446OtherBLUE SHIELD
TX1010100-01Medicaid
TX370017485OtherRR/MEDICARE
TX1010100-02OtherCSHCN
TX1010100-02OtherCSHCN
TX807446Medicare ID - Type Unspecified