Healthcare Provider Details

I. General information

NPI: 1477515021
Provider Name (Legal Business Name): PAUL SCOTT CHARNETSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 W LA MAR BLVD SUITE B
GOODYEAR AZ
85338-1389
US

IV. Provider business mailing address

13851 W LA MAR BLVD SUITE B
GOODYEAR AZ
85338-1389
US

V. Phone/Fax

Practice location:
  • Phone: 623-932-2200
  • Fax: 623-932-2242
Mailing address:
  • Phone: 623-932-2200
  • Fax: 623-932-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20645
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number20645
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: