Basic Information
| Provider Information | |||||||||
| NPI: | 1477655090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | CRAGIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4743 ARAPAHOE AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803031113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034449000 | ||||||||
| FaxNumber: | 3034449073 | ||||||||
| Practice Location | |||||||||
| Address1: | 4743 ARAPAHOE AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803031113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034449000 | ||||||||
| FaxNumber: | 3034449073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2006 | ||||||||
| LastUpdateDate: | 06/25/2014 | ||||||||
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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 | 174400000X | 40017 | CO | Y | Other Service Providers | Specialist |
No ID Information.