Provider Demographics
NPI:1558352724
Name:HOOGENDOORN, CHARLES MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARK
Last Name:HOOGENDOORN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4728
Mailing Address - Country:US
Mailing Address - Phone:209-239-1355
Mailing Address - Fax:209-239-7091
Practice Address - Street 1:440 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4728
Practice Address - Country:US
Practice Address - Phone:209-239-1355
Practice Address - Fax:209-239-7091
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0171940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0171940Medicare ID - Type Unspecified
U18611Medicare UPIN