Provider Demographics
NPI:1477655090
Name:ANDERSON, CHARLES CRAGIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CRAGIN
Last Name:ANDERSON
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 1:4743 ARAPAHOE AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1113
Mailing Address - Country:US
Mailing Address - Phone:303-444-9000
Mailing Address - Fax:303-444-9073
Practice Address - Street 1:4743 ARAPAHOE AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1113
Practice Address - Country:US
Practice Address - Phone:303-444-9000
Practice Address - Fax:303-444-9073
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40017174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG54430Medicare UPIN
CO452858Medicare ID - Type Unspecified