Provider Demographics
NPI:1265537831
Name:HEADRICK, CHARLES N (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:N
Last Name:HEADRICK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5525 ETIWANDA AVE
Mailing Address - Street 2:#201
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-996-8505
Mailing Address - Fax:818-996-8503
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:#201
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-996-8505
Practice Address - Fax:818-996-8503
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2009-04-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA 48418208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB23374Medicare UPIN
CABG022AMedicare PIN
B 23374Medicare UPIN