Healthcare Provider Details

I. General information

NPI: 1881937449
Provider Name (Legal Business Name): CHARLESTON CHUA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DR STE 103
SAN DIEGO CA
92121-3022
US

IV. Provider business mailing address

4510 EXECUTIVE DR STE 103
SAN DIEGO CA
92121-3022
US

V. Phone/Fax

Practice location:
  • Phone: 702-460-6009
  • Fax: 619-330-8826
Mailing address:
  • Phone: 702-460-6009
  • Fax: 916-734-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number21272
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA146435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: