Basic Information
| Provider Information | |||||||||
| NPI: | 1598758336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAERTER | ||||||||
| FirstName: | CHARLTON | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9225 N 3RD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024450751 | ||||||||
| FaxNumber: | 6024248128 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 E DUNLAP AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024450751 | ||||||||
| FaxNumber: | 6024248128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31842 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 31842 | AZ | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 842668 | 05 | AZ | MEDICAID |