Provider Demographics
NPI:1992735500
Name:ANDERSON, CHARLES PETER (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PETER
Last Name:ANDERSON
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:PO BOX 1804
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78667-1804
Mailing Address - Country:US
Mailing Address - Phone:512-491-3730
Mailing Address - Fax:512-268-9129
Practice Address - Street 1:900 REBEL ROAD UNIT 900
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640
Practice Address - Country:US
Practice Address - Phone:512-491-3730
Practice Address - Fax:512-268-9129
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121034601Medicaid
TXC12852Medicare UPIN
TX121034601Medicaid