Healthcare Provider Details

I. General information

NPI: 1124341060
Provider Name (Legal Business Name): MICHAEL R. CHIAROTTINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2010
Last Update Date: 03/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 BRIDGEWAY SUITE B105
SAUSALITO CA
94965-1993
US

IV. Provider business mailing address

1750 BRIDGEWAY SUITE B105
SAUSALITO CA
94965-1993
US

V. Phone/Fax

Practice location:
  • Phone: 415-331-2113
  • Fax: 415-331-2114
Mailing address:
  • Phone: 415-331-2113
  • Fax: 415-331-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number#G39528
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG39528
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: