Provider Demographics
NPI:1417793092
Name:FERRELL, CHARLIE IV (NP)
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:FERRELL
Suffix:IV
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 S FIGUEROA ST # 1125
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90071-1704
Mailing Address - Country:US
Mailing Address - Phone:310-263-8887
Mailing Address - Fax:
Practice Address - Street 1:545 S FIGUEROA ST # 1125
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90071-1704
Practice Address - Country:US
Practice Address - Phone:310-263-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95077364207QG0300X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine