Provider Demographics
NPI:1992796411
Name:METZGER, CHARLES KENNETH (MD MBA)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:METZGER
Suffix:
Gender:M
Credentials:MD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:412 W CARROLL AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4240
Mailing Address - Country:US
Mailing Address - Phone:626-335-0228
Mailing Address - Fax:626-914-9611
Practice Address - Street 1:412 W CARROLL AVE
Practice Address - Street 2:STE 200
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4240
Practice Address - Country:US
Practice Address - Phone:626-335-0228
Practice Address - Fax:626-914-9611
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG25299208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ72637ZMedicaid
W1349AMedicare ID - Type Unspecified
A42614Medicare UPIN