Healthcare Provider Details

I. General information

NPI: 1114112711
Provider Name (Legal Business Name): MARC D. CHALET, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2811 WILSHIRE BLVD SUITE 615
SANTA MONICA CA
90403-4803
US

IV. Provider business mailing address

2811 WILSHIRE BLVD SUITE 615
SANTA MONICA CA
90403-4803
US

V. Phone/Fax

Practice location:
  • Phone: 310-202-6204
  • Fax: 310-202-0831
Mailing address:
  • Phone: 310-202-6204
  • Fax: 310-202-0831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG38996
License Number StateCA

VIII. Authorized Official

Name: MARC D CHALET
Title or Position: OWNER
Credential: M.D.
Phone: 310-202-6204