Provider Demographics
NPI:1639105497
Name:TOBIN, CHARLENE D
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:D
Last Name:TOBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4058 WILLOWS RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-1668
Mailing Address - Country:US
Mailing Address - Phone:619-445-1188
Mailing Address - Fax:619-659-3140
Practice Address - Street 1:4058 WILLOWS RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1668
Practice Address - Country:US
Practice Address - Phone:619-445-1188
Practice Address - Fax:619-659-3140
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ967721Medicaid
F77466Medicare UPIN