Provider Demographics
NPI:1538475793
Name:HARDISON, CHARLES LYNN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LYNN
Last Name:HARDISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:120 CRAVEN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4237
Mailing Address - Country:US
Mailing Address - Phone:760-291-6650
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:211 13TH ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2711
Practice Address - Country:US
Practice Address - Phone:760-789-5160
Practice Address - Fax:760-789-6316
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG70382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG70382OtherMEDICAL LICENSE