Provider Demographics
NPI:1780613588
Name:CHALET, MARC DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:DAVID
Last Name:CHALET
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 1:2811 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4803
Mailing Address - Country:US
Mailing Address - Phone:310-828-4071
Mailing Address - Fax:310-828-6734
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 615
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4803
Practice Address - Country:US
Practice Address - Phone:310-828-4071
Practice Address - Fax:310-828-6734
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38996207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G389960OtherBLUE SHIELD
CA00G389960Medicaid
CAG38996OtherBLUE CROSS
CAG38996AMedicare PIN
CAG38996OtherBLUE CROSS