Provider Demographics
NPI:1699794552
Name:ANDERSON, CHARLA LYNN (MD)
Entity type:Individual
Prefix:MS
First Name:CHARLA
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 EOFF ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3823
Mailing Address - Country:US
Mailing Address - Phone:304-234-8663
Mailing Address - Fax:304-234-8960
Practice Address - Street 1:2115 CHAPLINE ST STE 105
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3859
Practice Address - Country:US
Practice Address - Phone:304-234-3410
Practice Address - Fax:304-234-8605
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18847WV207Q00000X
OH35071519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2044577Medicaid
WV0048008000Medicaid
WV0854531Medicare PIN
OH2044577Medicaid
WVWV1471BMedicare PIN