Provider Demographics
NPI:1942273917
Name:WEATHERBY, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:WEATHERBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1145 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-860-5414
Mailing Address - Fax:206-720-8462
Practice Address - Street 1:1812 S J ST STE 102
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4965
Practice Address - Country:US
Practice Address - Phone:253-552-4900
Practice Address - Fax:253-627-1886
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-04-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00019117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1022508Medicaid
WAGAB10406Medicare ID - Type Unspecified
WAA08645Medicare UPIN