Healthcare Provider Details

I. General information

NPI: 1861056699
Provider Name (Legal Business Name): CHARLES BOADU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

5134 BALLANTRAE BLVD
LAND O LAKES FL
34638-3065
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3000
  • Fax:
Mailing address:
  • Phone: 718-791-6887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number200762
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME152416
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME152416
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: