Healthcare Provider Details

I. General information

NPI: 1063472009
Provider Name (Legal Business Name): CHARLES JACKSON VANMETER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 THOMAS JOHNSON DR STE A
FREDERICK MD
21702-4301
US

IV. Provider business mailing address

63 THOMAS JOHNSON DR STE A
FREDERICK MD
21702-4301
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-0400
  • Fax: 301-663-1906
Mailing address:
  • Phone: 301-663-0400
  • Fax: 301-663-1906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberD26357
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: