Provider Demographics
NPI:1558358507
Name:KENDALL, CHARLES MARTIN (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MARTIN
Last Name:KENDALL
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 1:512 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1199
Mailing Address - Country:US
Mailing Address - Phone:218-879-4641
Mailing Address - Fax:218-879-9167
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1199
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:218-879-9167
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN966380100Medicaid
MN080006276Medicare ID - Type Unspecified
MN966380100Medicaid