Basic Information
| Provider Information | |||||||||
| NPI: | 1366461741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMBLEE | ||||||||
| FirstName: | COBRA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 LAKE SUMTER LNDG | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748905 | ||||||||
| FaxNumber: | 3526748901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 BROWNWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321632032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526741790 | ||||||||
| FaxNumber: | 3526748990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K8686 | TX | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS17772 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.