Healthcare Provider Details

I. General information

NPI: 1588285910
Provider Name (Legal Business Name): CASEY LEONARD CHARLTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 E 120TH ST
LOS ANGELES CA
90059-3026
US

IV. Provider business mailing address

5504 S GARTH AVE
LOS ANGELES CA
90056-1309
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-8000
  • Fax:
Mailing address:
  • Phone: 310-702-1883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR78026
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1588285910
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: