Healthcare Provider Details

I. General information

NPI: 1902881808
Provider Name (Legal Business Name): CHARLES VINCENT PANADERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 AUBURN BLVD
SACRAMENTO CA
95841-4100
US

IV. Provider business mailing address

PO BOX 1956
ROCKLIN CA
95677-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-489-3336
  • Fax:
Mailing address:
  • Phone: 916-761-4668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA77796
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: