Provider Demographics
NPI:1790779890
Name:ANDERSON, CHARLES D (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 24TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6313
Mailing Address - Country:US
Mailing Address - Phone:405-360-9338
Mailing Address - Fax:405-366-1669
Practice Address - Street 1:817 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6313
Practice Address - Country:US
Practice Address - Phone:405-360-9338
Practice Address - Fax:405-366-1669
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK190213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779900AMedicaid
OK100779900AMedicaid
OK1163970001Medicare NSC
OKU57180Medicare UPIN