Provider Demographics
NPI:1508999715
Name:MCCAMMON, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MCCAMMON
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 1:6235 RIVER CREST DR
Mailing Address - Street 2:SUITE L
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0758
Mailing Address - Country:US
Mailing Address - Phone:951-413-1200
Mailing Address - Fax:
Practice Address - Street 1:6235 RIVER CREST DR
Practice Address - Street 2:SUITE L
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0758
Practice Address - Country:US
Practice Address - Phone:951-413-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51047OtherLICENSE NUMBER
CAA51882Medicare UPIN