Provider Demographics
NPI:1851328991
Name:MCCORMICK, CHARLES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:MCCORMICK
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 1:1240 W ROBINHOOD DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5507
Mailing Address - Country:US
Mailing Address - Phone:209-472-1470
Mailing Address - Fax:209-472-1961
Practice Address - Street 1:1240 W ROBINHOOD DR
Practice Address - Street 2:SUITE G
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5507
Practice Address - Country:US
Practice Address - Phone:209-472-1470
Practice Address - Fax:209-472-1961
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35177208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA721556520OtherTAX ID
CAG35177OtherSTATE LICENSE
CAAM9043770OtherDEA