MEDICARE: COLIN ROBERT CHALOUPECKY MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207QS0010X	Sports Medicine (Family Medicine) Physician	ME167666	FL
3	207Q00000X	Family Medicine Physician	68726	TN

General Provider Information

NPI Number	:	1922637800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLIN ROBERT CHALOUPECKY MD

Provider Business Mailing Address
First Line	:	201 VILLAGE OAKS DR
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-3876
Country	:	US
Telephone Number	:	904-240-0442
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 VILLAGE OAKS DR
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-3876
Country	:	US
Telephone Number	:	904-240-0442
Fax Number	:

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

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	06/21/2024

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