Provider Demographics
NPI:1174554059
Name:CHUATECO, CAROUCEL KIM (MD)
Entity type:Individual
Prefix:DR
First Name:CAROUCEL
Middle Name:KIM
Last Name:CHUATECO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1663 BEVERLY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5747
Mailing Address - Country:US
Mailing Address - Phone:213-250-0235
Mailing Address - Fax:213-250-0439
Practice Address - Street 1:1663 BEVERLY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5747
Practice Address - Country:US
Practice Address - Phone:213-250-0235
Practice Address - Fax:213-250-0439
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A85249Medicaid
CA00A85249Medicaid
CAWA85249CMedicare ID - Type Unspecified