Provider Demographics
NPI:1467534479
Name:ROBERTSON, CHARLES DONALD II (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DONALD
Last Name:ROBERTSON
Suffix:II
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 SUTTON LN
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:WV
Mailing Address - Zip Code:26601-9717
Mailing Address - Country:US
Mailing Address - Phone:304-750-2092
Mailing Address - Fax:304-750-2093
Practice Address - Street 1:2258 SUTTON LN
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:WV
Practice Address - Zip Code:26601-9717
Practice Address - Country:US
Practice Address - Phone:304-750-2092
Practice Address - Fax:304-750-2093
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV699111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1070496OtherBRICKSTREET VENDOR #
WV699OtherSTATE LICENSE #
WV74-318-5632OtherTAX I.D. #