Provider Demographics
NPI:1508899808
Name:CHARUWORN, BURT (MD)
Entity Type:Individual
Prefix:DR
First Name:BURT
Middle Name:
Last Name:CHARUWORN
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 1:1245 16TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1235
Mailing Address - Country:US
Mailing Address - Phone:310-828-0174
Mailing Address - Fax:310-828-2824
Practice Address - Street 1:1245 16TH ST
Practice Address - Street 2:#204
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1235
Practice Address - Country:US
Practice Address - Phone:310-828-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73156207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508899808Medicare UPIN