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General NPI Number Information
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NPI Number | 1790288280
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Entity Type | Individual
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Provider Name | CHARLES M. LLEWELLYN MD
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Gender | Male
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Dates
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Enumeration Date | 03/12/2018
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Last Update Date | 02/20/2025
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Provider Practice Location Address
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Address Line | 9040 JACKSON AVE
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City | TACOMA
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State | WA
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Zip | 98431-0001
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Country | US
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Telephone | 253-968-1420
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Fax | 253-968-3140
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Provider Business Mailing Address
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Address Line | 9040 JACKSON AVE
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City | TACOMA
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State | WA
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Zip | 98431-0001
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Country | US
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Telephone | 253-968-1420
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | A186385
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | A186385
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 32149
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License Number State | NE
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Taxonomy #4
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number | MD61640327
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License Number State | WA
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