Provider Demographics
NPI:1689419848
Name:CHACON ORELLANA, CARMEN VICTORIA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN VICTORIA
Middle Name:
Last Name:CHACON ORELLANA
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 1:2624 E CACTUS RD APT 4123
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7043
Mailing Address - Country:US
Mailing Address - Phone:404-790-2624
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-839-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR81674390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program