Provider Demographics
NPI:1942376850
Name:DARBY, CHARLES L (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:DARBY
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 1:4212 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1460
Mailing Address - Country:US
Mailing Address - Phone:503-249-8787
Mailing Address - Fax:
Practice Address - Street 1:4212 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1460
Practice Address - Country:US
Practice Address - Phone:503-249-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10606-2Medicaid
OR10606-2Medicaid
OR011WCBBWEMedicare ID - Type Unspecified