MEDICARE: CHARLES HOMOLKA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	ME70760	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	050046654	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32297	OTHER	FL	BC/BS FL
2	222990	OTHER		AMERIGROUP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114907664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES HOMOLKA M.D.

Provider Business Mailing Address
First Line	:	11760 HAMPTON GREENS DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33913-8325
Country	:	US
Telephone Number	:	239-939-2622
Fax Number	:	239-939-0151

Provider Business Practice Location Address
First Line	:	12511 WORLD PLAZA LN BLDG 50
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3991
Country	:	US
Telephone Number	:	239-939-2622
Fax Number	:	239-939-0151

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	03/01/2024

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Directions to “ CHARLES HOMOLKA M.D.” Practice Location

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