Basic Information
| Provider Information | |||||||||
| NPI: | 1437138971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHACON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | CARLOS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 N TUSTIN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008837243 | ||||||||
| FaxNumber: | 7146471245 | ||||||||
| Practice Location | |||||||||
| Address1: | 27882 FORBES RD | ||||||||
| Address2: | STE 203 | ||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926771267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493472400 | ||||||||
| FaxNumber: | 9493472424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A74564 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A745640 | 05 | CA | MEDICAID |