Provider Demographics
NPI:1285977710
Name:VONN, CHARLOTTE ASTRID VIVIENNE (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ASTRID VIVIENNE
Last Name:VONN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:RAE
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:200 W 134TH PL
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-4143
Mailing Address - Country:US
Mailing Address - Phone:985-325-9333
Mailing Address - Fax:
Practice Address - Street 1:2106 LOOP RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3344
Practice Address - Country:US
Practice Address - Phone:318-435-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207500207Q00000X, 207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1D1629OtherMEDICARE
14679366OtherCAQH
LA2329260Medicaid
LAP02480315OtherRR MEDICARE