Provider Demographics
NPI:1174504252
Name:ATHILL, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:ATHILL
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 1:3131 BERGER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4233
Mailing Address - Country:US
Mailing Address - Phone:858-244-6800
Mailing Address - Fax:858-244-6909
Practice Address - Street 1:3131 BERGER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4233
Practice Address - Country:US
Practice Address - Phone:858-244-6800
Practice Address - Fax:858-244-6909
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78671207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G786710Medicaid
CAWG78671AMedicare PIN
CAG66098Medicare UPIN