1679785695 NPI number — CHRISTOPHER J. CHARBONNET, M.D., A PROFESSIONAL CORPORATION

Table of content: (NPI 1679785695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679785695 NPI number — CHRISTOPHER J. CHARBONNET, M.D., A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER J. CHARBONNET, M.D., A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679785695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5486
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92863-5486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-550-0900
Provider Business Mailing Address Fax Number:
505-293-1524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1530 E CHEVY CHASE DR
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91206-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-241-7246
Provider Business Practice Location Address Fax Number:
505-293-1524
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHARBONNET
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-550-0900

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  G79131 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G791310 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G791310 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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