Provider Demographics
NPI:1477723799
Name:NATHAN, CHARLES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:NATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:17300 N. OUTER 40 RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-530-6161
Mailing Address - Fax:636-777-7500
Practice Address - Street 1:845 N NEW BALLAS CT
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7134
Practice Address - Country:US
Practice Address - Phone:314-569-0130
Practice Address - Fax:314-569-3674
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD1100272086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240007092OtherRR MEDICARE
MO240007092OtherRR MEDICARE