Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 24257 | IA |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 24257 | IA |
NPI | 1225016009 |
---|---|
Provider Name | Charles B Vernon |
First Address | Anamosa, IA 52205-2112 |
Second Address | Anamosa, IA 52205-2112 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2006 |
Last Update Date | 16/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
080116811 | RR MEDICARE (01) | IA |
1225016009 | (05) | IA |
3019570 | (05) | IA |
A02563 | (02) |