Healthcare Provider Details

I. General information

NPI: 1790779890
Provider Name (Legal Business Name): CHARLES D ANDERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 24TH AVE NW
NORMAN OK
73069-6313
US

IV. Provider business mailing address

817 24TH AVE NW
NORMAN OK
73069-6313
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-9338
  • Fax: 405-366-1669
Mailing address:
  • Phone: 405-360-9338
  • Fax: 405-366-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number190
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: