Basic Information
| Provider Information | |||||||||
| NPI: | 1912001561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANNER | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056210023 | ||||||||
| FaxNumber: | 3056239188 | ||||||||
| Practice Location | |||||||||
| Address1: | 20801 NW 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056531770 | ||||||||
| FaxNumber: | 7867253453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME58914 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26696Z | 01 | FL | MEDICARE ID | OTHER |