Provider Demographics
NPI:1720072390
Name:ANDERSON, CHARLES LEON JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEON
Last Name:ANDERSON
Suffix:JR
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 1:23 CRAIGIE TER
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02460-2106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090
Practice Address - Country:US
Practice Address - Phone:781-686-1608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA755832080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3127991Medicaid
MA3127991Medicaid
F83155Medicare UPIN