Healthcare Provider Details

I. General information

NPI: 1164676771
Provider Name (Legal Business Name): DJRJ2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 NW AMERICAN LN
LAKE CITY FL
32055-8841
US

IV. Provider business mailing address

PO BOX 805
LAKE CITY FL
32056-0805
US

V. Phone/Fax

Practice location:
  • Phone: 386-365-3845
  • Fax:
Mailing address:
  • Phone: 386-755-9190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME82558
License Number StateFL

VIII. Authorized Official

Name: DR. JOSEPH MICHAEL CHARL3S JR.
Title or Position: OWNER
Credential: MD
Phone: 386-365-3845