Provider Demographics
NPI:1902881808
Name:PANADERO, CHARLES VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:VINCENT
Last Name:PANADERO
Suffix:
Gender:M
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:PO BOX 1956
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-7956
Mailing Address - Country:US
Mailing Address - Phone:916-761-4668
Mailing Address - Fax:
Practice Address - Street 1:4250 AUBURN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4100
Practice Address - Country:US
Practice Address - Phone:916-489-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA777962084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A777960Medicaid