Provider Demographics
NPI:1174544845
Name:LEDERER, CHARLES M JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:LEDERER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2905 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2427
Mailing Address - Country:US
Mailing Address - Phone:913-327-1041
Mailing Address - Fax:
Practice Address - Street 1:506 BURKARTH RD
Practice Address - Street 2:A
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3104
Practice Address - Country:US
Practice Address - Phone:660-747-2202
Practice Address - Fax:660-747-1223
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8629207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09486042OtherBLUE CROSS BLUE SHIELD
MO09486052OtherBLUE CROSS BLUE SHIELD
MOP00355817Medicare PIN
MO6315052Medicare PIN
MOM525052Medicare PIN
MO09486042OtherBLUE CROSS BLUE SHIELD
MOC50456Medicare UPIN