Provider Demographics
NPI:1124292263
Name:GROOTERS, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GROOTERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 E HAWKINS PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7905
Mailing Address - Country:US
Mailing Address - Phone:903-758-2746
Mailing Address - Fax:903-758-7127
Practice Address - Street 1:323 E HAWKINS PKWY STE A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7905
Practice Address - Country:US
Practice Address - Phone:903-758-2746
Practice Address - Fax:903-758-7127
Is Sole Proprietor?:No
Enumeration Date:2008-04-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4967207X00000X
GA060461207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350010001Medicaid
TXQ4967OtherTEXAS MEDICAL BOARD