Provider Demographics
NPI:1528031069
Name:NORDSTROM, CHARLES R JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:NORDSTROM
Suffix:JR
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 1:127 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7105
Mailing Address - Country:US
Mailing Address - Phone:715-835-1884
Mailing Address - Fax:
Practice Address - Street 1:127 CANTERBURY RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7105
Practice Address - Country:US
Practice Address - Phone:715-835-1884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21796207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30184300Medicaid
WI0123 00502Medicare PIN
B55403Medicare UPIN
WI0060 20195Medicare ID - Type Unspecified
WI0167 00507Medicare PIN