Provider Demographics
NPI:1114907664
Name:HOMOLKA, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:HOMOLKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11760 HAMPTON GREENS DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8325
Mailing Address - Country:US
Mailing Address - Phone:239-939-2622
Mailing Address - Fax:239-939-0151
Practice Address - Street 1:12511 WORLD PLAZA LN BLDG 50
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3991
Practice Address - Country:US
Practice Address - Phone:239-939-2622
Practice Address - Fax:239-939-0151
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70760207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32297OtherBC/BS FL
222990OtherAMERIGROUP
FL252581000Medicaid
050046654OtherRAILROAD MEDICARE
FL252581000Medicaid
FL32297OtherBC/BS FL
FL252581000Medicaid