Provider Demographics
NPI:1104863661
Name:CHARLTON, TIMOTHY P (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:CHARLTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1162
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-0001
Mailing Address - Country:US
Mailing Address - Phone:323-442-5808
Mailing Address - Fax:323-442-6296
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:2000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5860
Practice Address - Fax:323-442-6990
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92746207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A927460OtherBLUE SHIELD
CA00A927460OtherBLUE SHIELD
CAI47984Medicare UPIN