Provider Demographics
NPI:1437138971
Name:CHACON, ANDREW CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:CARLOS
Last Name:CHACON
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:27882 FORBES RD
Practice Address - Street 2:STE 203
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-1267
Practice Address - Country:US
Practice Address - Phone:949-347-2400
Practice Address - Fax:949-347-2424
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74564207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A745640Medicaid
CA00A745640Medicaid
CAA74564Medicare PIN
H85698Medicare UPIN
CABV081AMedicare PIN
CAP00807652Medicare PIN