Healthcare Provider Details

I. General information

NPI: 1922192046
Provider Name (Legal Business Name): CHARLES ANTHONY SKIBA JR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9229 WILSHIRE BLVD # 1
BEVERLY HILLS CA
90210-5501
US

IV. Provider business mailing address

PO BOX 462051
LOS ANGELES CA
90046-8051
US

V. Phone/Fax

Practice location:
  • Phone: 323-939-1603
  • Fax: 323-939-1643
Mailing address:
  • Phone: 323-939-1603
  • Fax: 323-939-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9707
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A9707
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: