Provider Demographics
NPI:1679785695
Name:CHRISTOPHER J. CHARBONNET, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CHRISTOPHER J. CHARBONNET, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHARBONNET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-550-0900
Mailing Address - Street 1:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:505-293-1524
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:STE 204
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4163
Practice Address - Country:US
Practice Address - Phone:818-241-7246
Practice Address - Fax:505-293-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79131208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G791310Medicaid
CA00G791310OtherBLUE SHIELD
CA00G791310OtherBLUE SHIELD
CAG79131BMedicare ID - Type Unspecified