Provider Demographics
NPI:1629057625
Name:WALWORTH, CHARLES M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:WALWORTH
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 1:1380 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1447
Mailing Address - Country:US
Mailing Address - Phone:949-376-5731
Mailing Address - Fax:
Practice Address - Street 1:11190 WARNER AVE
Practice Address - Street 2:SUITE 411
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4019
Practice Address - Country:US
Practice Address - Phone:714-751-5800
Practice Address - Fax:714-751-5860
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG31935Medicare UPIN
CAW14601Medicare ID - Type UnspecifiedGROUP