Healthcare Provider Details

I. General information

NPI: 1538475793
Provider Name (Legal Business Name): CHARLES LYNN HARDISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 13TH ST
RAMONA CA
92065-2711
US

IV. Provider business mailing address

120 CRAVEN RD STE 201
SAN MARCOS CA
92078-4237
US

V. Phone/Fax

Practice location:
  • Phone: 760-789-5160
  • Fax: 760-789-6316
Mailing address:
  • Phone: 760-291-6650
  • Fax: 858-618-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG70382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: