Basic Information
Provider Information | |||||||||
NPI: | 1104114651 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAWSON | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 833 POMAHINA PL | ||||||||
Address2: |   | ||||||||
City: | KAILUA | ||||||||
State: | HI | ||||||||
PostalCode: | 967343549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8083491985 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 795 WILLOW RD BLDG 334 | ||||||||
Address2: |   | ||||||||
City: | MENLO PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 940252539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8777805559 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2011 | ||||||||
LastUpdateDate: | 04/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A124225 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | A124225 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
ID | Type | State | Issuer | Description | A124225 | 01 | CA | CALIFORNIA MEDICAL BOARD (LICENSE) | OTHER |