Provider Demographics
NPI:1720197635
Name:ANDERSON, CHARLES G JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:ANDERSON
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 1:1680 ANTILLEY RD
Mailing Address - Street 2:STE 350
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5267
Mailing Address - Country:US
Mailing Address - Phone:325-428-5570
Mailing Address - Fax:325-428-5579
Practice Address - Street 1:1680 ANTILLEY RD STE 350
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5266
Practice Address - Country:US
Practice Address - Phone:325-704-5200
Practice Address - Fax:325-704-5202
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2894207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114447904Medicaid
TXC12822Medicare UPIN
TX85820BMedicare ID - Type Unspecified