Provider Demographics
NPI:1790288280
Name:LLEWELLYN, CHARLES M (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:LLEWELLYN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-1420
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1420
Practice Address - Fax:253-968-3140
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA186385207YS0123X, 207YX0007X
NE32149208D00000X
WAMD61640327207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice