Provider Demographics
NPI:1245229319
Name:CHABOLLA, DAVID ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROGER
Last Name:CHABOLLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 SHIRCLIFF WAY
Mailing Address - Street 2:SUITE 724
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4786
Mailing Address - Country:US
Mailing Address - Phone:904-308-7959
Mailing Address - Fax:904-308-7938
Practice Address - Street 1:4205 BELFORT RD STE 1100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5876
Practice Address - Country:US
Practice Address - Phone:904-450-6300
Practice Address - Fax:904-281-5966
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME686562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL130012335OtherRAILROAD MEDICARE
FL27473OtherBLUECROSS/BLUESHIELD
FL268609100Medicaid
FL130012335OtherRAILROAD MEDICARE
FLF45038Medicare UPIN