Healthcare Provider Details

I. General information

NPI: 1164480133
Provider Name (Legal Business Name): CHARLES W ANDERSON MEDICAL DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 08/31/2007

III. Provider practice location address

123 CRUZ ALTA
TAOS NM
87571-6279
US

IV. Provider business mailing address

123 CRUZ ALTA
TAOS NM
87571-6279
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-8651
  • Fax: 505-758-7811
Mailing address:
  • Phone: 505-758-8651
  • Fax: 505-758-8711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number64-23
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: