Provider Demographics
NPI:1134211170
Name:MCCRORY, CHARLES THOMAS (MD, DC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:MCCRORY
Suffix:
Gender:M
Credentials:MD, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HARDING BLVD
Mailing Address - Street 2:213
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2474
Mailing Address - Country:US
Mailing Address - Phone:916-780-2800
Mailing Address - Fax:916-780-1130
Practice Address - Street 1:300 HARDING BLVD
Practice Address - Street 2:213
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2474
Practice Address - Country:US
Practice Address - Phone:916-780-2800
Practice Address - Fax:916-780-1130
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24046111N00000X
CAA066088208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A660880Medicare ID - Type Unspecified
CAG89111Medicare UPIN