Provider Demographics
NPI:1720020373
Name:CHARBONNEAU, PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:CHARBONNEAU
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 1:8 PARK PL
Mailing Address - Street 2:#302-M
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1567
Mailing Address - Country:US
Mailing Address - Phone:601-264-9982
Mailing Address - Fax:
Practice Address - Street 1:6051 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17545207P00000X
TXM8587207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1720020373OtherBCBXTX
TX193109901Medicaid
TX1720020373OtherTRICARE SOUTH
MS03923081Medicaid
TX8BB100OtherBLUE CROSS BLUE SHIELD TX
H76012Medicare UPIN
TXP00605650Medicare PIN
TX1720020373OtherTRICARE SOUTH
MS03923081Medicaid