Provider Demographics
NPI:1285625327
Name:RUTHERFORD, CHARLES S (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:RUTHERFORD
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 1:7777 FOREST LN
Mailing Address - Street 2:STE. C-300G
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-566-5564
Mailing Address - Fax:972-566-3556
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:STE. C-300G
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-5564
Practice Address - Fax:972-566-3556
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7125207XS0114X, 207X00000X, 207XS0106X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123776005Medicaid
TX8A5013OtherBCBS
B26069Medicare UPIN
TX8A5013OtherBCBS
TX200041256Medicare PIN