Provider Demographics
NPI:1952417925
Name:ANDERSON, CHARLES T (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:233 WILLIAMS AVE
Mailing Address - Street 2:PO BOX 508
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564-0508
Mailing Address - Country:US
Mailing Address - Phone:360-983-3069
Mailing Address - Fax:360-983-3098
Practice Address - Street 1:521 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356
Practice Address - Country:US
Practice Address - Phone:360-496-5145
Practice Address - Fax:360-496-6449
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041818208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8324857Medicaid
WAAB35319Medicare ID - Type UnspecifiedMEDICARE ID
WA8324857Medicaid