Provider Demographics
NPI:1700955143
Name:CHARNEY, MICHAEL TANDICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TANDICK
Last Name:CHARNEY
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 1:2100 FOREST AVE
Mailing Address - Street 2:#106
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1422
Mailing Address - Country:US
Mailing Address - Phone:408-286-6470
Mailing Address - Fax:408-286-2570
Practice Address - Street 1:2100 FOREST AVE
Practice Address - Street 2:#106
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1422
Practice Address - Country:US
Practice Address - Phone:408-286-6470
Practice Address - Fax:408-286-2570
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22044207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G220440Medicaid
CA770438724OtherITIN
CA00G220440Medicare ID - Type UnspecifiedMEDICARE
CA00G220440Medicaid