Healthcare Provider Details

I. General information

NPI: 1114362175
Provider Name (Legal Business Name): CHARLES PHILIP BLACKSHEAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2013
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 I ST
SACRAMENTO CA
95814-2400
US

IV. Provider business mailing address

2613 KLINE CT
DAVIS CA
95618-7668
US

V. Phone/Fax

Practice location:
  • Phone: 916-874-6752
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA145515
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: