Basic Information
| Provider Information | |||||||||
| NPI: | 1437167574 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 10/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A37278 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A372780 | 01 | CA | BLUE SHIELD | OTHER | 1291919 | 01 | CA | GREAT WEST | OTHER | 36081 | 01 | CA | INTERPLAN | OTHER | 509520 | 01 | CA | FIRST HEALTH | OTHER | 5410051 | 01 | CA | AETNA | OTHER | A37278 | 01 | CA | BLUE CROSS | OTHER | MCMG168800 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER | 00A372780 | 05 | CA | MEDICAID | 6966655 | 01 | CA | CIGNA | OTHER | 820636 | 01 | CA | UNITED HEALTHCARE | OTHER | 90021916 | 01 | CA | PACIFICARE | OTHER | 000810342676 | 01 | CA | PHCS | OTHER | 047729 | 01 | CA | HEALTH NET | OTHER |