1366767485 NPI number — DR. CARRIE CHANSON M.D., DR.PH, MPM

Table of content: DR. CARRIE CHANSON M.D., DR.PH, MPM (NPI 1366767485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366767485 NPI number — DR. CARRIE CHANSON M.D., DR.PH, MPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANSON
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., DR.PH, MPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHENG
Provider Other First Name:
MING YU
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366767485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 COMMERCIAL RD STE 101
Provider Second Line Business Mailing Address:
LOMA LINDA OCCUPATIONAL MEDICINE CLINIC
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92408-3766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-6662
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 COMMERCIAL RD STE 101
Provider Second Line Business Practice Location Address:
LOMA LINDA OCCUPATIONAL MEDICINE CLINIC
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92408-3766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-558-6662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083X0100X , with the licence number:  A122043 , 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)