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General NPI Number Information
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NPI Number | 1790126316
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Entity Type | Individual
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Provider Name | CARLOS O CHACON M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/11/2013
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Last Update Date | 08/06/2015
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Provider Practice Location Address
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Address Line | 180 OTAY LAKES RD 110
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City | BONITA
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State | CA
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Zip | 91902-2443
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Country | US
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Telephone | 858-633-7546
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Fax | 760-634-6785
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Provider Business Mailing Address
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Address Line | 384 MINOT AVE
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City | CHULA VISTA
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State | CA
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Zip | 91910-2937
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Country | US
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Telephone | 858-633-7546
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Fax | 760-634-6785
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | A98477
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License Number State | CA
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