Basic Information
| Provider Information | |||||||||
| NPI: | 1679785695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTOPHER J. CHARBONNET, M.D., A PROFESSIONAL CORPORATION | ||||||||
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| 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: | STE 204 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912064163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182417246 | ||||||||
| FaxNumber: | 5052931524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHARBONNET | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8185500900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | G79131 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | 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 |