Provider Demographics
NPI:1992883664
Name:PERRY, CHARLES W (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:PERRY
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 1:785 UNIVERSITY AVE
Mailing Address - Street 2:CHRYSALIS COSMETICS
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6708
Mailing Address - Country:US
Mailing Address - Phone:916-273-7435
Mailing Address - Fax:
Practice Address - Street 1:785 UNIVERSITY AVE
Practice Address - Street 2:CHRYSALIS COSMETICS
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6708
Practice Address - Country:US
Practice Address - Phone:916-273-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87534208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A875340Medicaid
I19589Medicare UPIN
CA00A875340Medicaid