Provider Demographics
NPI:1225049968
Name:CHARBONNET, CHRISTOPHER J (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:CHARBONNET
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:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:505-293-1524
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4163
Practice Address - Country:US
Practice Address - Phone:818-241-7246
Practice Address - Fax:818-241-1639
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79131207L00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G791310Medicaid
CA00G791310OtherBLUE SHIELD
CA00G791310Medicaid
CA00G791310OtherBLUE SHIELD