Basic Information
| Provider Information | |||||||||
| NPI: | 1669411732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SODERSTROM | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7026 OLD KATY RD | ||||||||
| Address2: | SUITE 276 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136217436 | ||||||||
| FaxNumber: | 7139639051 | ||||||||
| Practice Location | |||||||||
| Address1: | 7026 OLD KATY RD | ||||||||
| Address2: | SUITE 276 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136217436 | ||||||||
| FaxNumber: | 7139639051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | J0869 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CS7910 | 01 | TX | MEDICARE RAILROAD GROUP | OTHER | 083133101 | 01 | TX | MEDICAID GROUP | OTHER | 10016860 | 01 | TX | AMERIGROUP | OTHER | 101475502 | 05 | TX | MEDICAID | 300063727 | 01 | TX | MEDICARE RAILROAD | OTHER | 00J245 | 01 | TX | MEDICARE GROUP | OTHER |