Healthcare Provider Details

I. General information

NPI: 1588126759
Provider Name (Legal Business Name): DERALD CHARLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3619 PACIFIC AVE
TACOMA WA
98418-7929
US

IV. Provider business mailing address

3619 PACIFIC AVE
TACOMA WA
98418-7921
US

V. Phone/Fax

Practice location:
  • Phone: 253-798-6494
  • Fax: 253-798-2893
Mailing address:
  • Phone: 253-798-6494
  • Fax: 253-798-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberMD61622864
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: