Provider Demographics
NPI:1487739298
Name:MAYER, CHARLES JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JACOB
Last Name:MAYER
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 1:1420 5TH AVE STE 375
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-4032
Mailing Address - Country:US
Mailing Address - Phone:206-223-2611
Mailing Address - Fax:
Practice Address - Street 1:1420 5TH AVE STE 375
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-4032
Practice Address - Country:US
Practice Address - Phone:206-223-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0067844207Q00000X
WAMD00031331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8182313Medicaid
2000015OtherINTERNAL ID-MOTOR VEHICLE ID
WAG8881538Medicare PIN
WAG8881539Medicare PIN
000151415Medicare ID - Type Unspecified
2000015OtherINTERNAL ID-MOTOR VEHICLE ID