Provider Demographics
NPI:1962813790
Name:CHARLES RICHARD UNDERWOOD MD PLLC
Entity Type:Organization
Organization Name:CHARLES RICHARD UNDERWOOD MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-514-7734
Mailing Address - Street 1:400 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5519
Mailing Address - Country:US
Mailing Address - Phone:239-595-6687
Mailing Address - Fax:
Practice Address - Street 1:400 8TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5519
Practice Address - Country:US
Practice Address - Phone:239-595-6687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38081261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30421YMedicare PIN