Provider Demographics
NPI:1255512075
Name:CHARLES W. CHIDSEY III, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CHARLES W. CHIDSEY III, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHIDSEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:818-363-9732
Mailing Address - Street 1:17075 DEVONSHIRE ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5405
Mailing Address - Country:US
Mailing Address - Phone:818-363-9732
Mailing Address - Fax:818-363-9853
Practice Address - Street 1:17075 DEVONSHIRE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5405
Practice Address - Country:US
Practice Address - Phone:818-363-9732
Practice Address - Fax:818-363-9853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G465240OtherBLUE SHIELD
CA00G465240Medicaid
CAG46524OtherBLUE CROSS
CA00G465240OtherBLUE SHIELD