Provider Demographics
NPI:1841355054
Name:ROBERTSON, CHARLES (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5184
Practice Address - Fax:781-306-5080
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3368152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0312932Medicaid
MA8278875-002OtherCIGNA
MAW16027OtherBCBS
MA0014539OtherNHP
MA003368OtherTUFTS
MAU58224Medicare UPIN
MAQX4853Medicare PIN