Basic Information
Provider Information | |||||||||
NPI: | 1225049968 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHARBONNET | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5486 | ||||||||
Address2: |   | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 928635486 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8185500900 | ||||||||
FaxNumber: | 5052931524 | ||||||||
Practice Location | |||||||||
Address1: | 1530 E CHEVY CHASE DR | ||||||||
Address2: | SUITE 204 | ||||||||
City: | GLENDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 912064163 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182417246 | ||||||||
FaxNumber: | 8182411639 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 10/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G79131 | CA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 208VP0000X | G79131 | CA | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | G79131 | CA | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 00G791310 | 05 | CA |   | MEDICAID | 00G791310 | 01 | CA | BLUE SHIELD | OTHER |