Provider Demographics
NPI:1205980745
Name:PADDACK, CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:PADDACK
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 1:2848 S LAKERIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9374
Mailing Address - Country:US
Mailing Address - Phone:720-519-0949
Mailing Address - Fax:720-519-0948
Practice Address - Street 1:2848 S LAKERIDGE TRL
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-9374
Practice Address - Country:US
Practice Address - Phone:720-519-0949
Practice Address - Fax:720-519-0948
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO468072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD788111800Medicaid
158771Medicare ID - Type Unspecified
C88011Medicare UPIN