Provider Demographics
NPI:1841384203
Name:CHARP, KENNETH GARY (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GARY
Last Name:CHARP
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 1:2982 CARRILLO WAY
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-3027
Mailing Address - Country:US
Mailing Address - Phone:760-744-6226
Mailing Address - Fax:760-744-6277
Practice Address - Street 1:1553 GRAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2427
Practice Address - Country:US
Practice Address - Phone:760-744-6226
Practice Address - Fax:760-744-6277
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE15360213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E15360Medicare ID - Type UnspecifiedMEDICARE NUMBER