Provider Demographics
NPI:1255492427
Name:SCHALLOP, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:SCHALLOP
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:PO BOX 30308
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33420-0308
Mailing Address - Country:US
Mailing Address - Phone:561-630-6939
Mailing Address - Fax:561-630-9221
Practice Address - Street 1:500 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2773
Practice Address - Country:US
Practice Address - Phone:561-630-6939
Practice Address - Fax:560-630-9221
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59068174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055367100Medicaid
FLE80140Medicare UPIN
FL055367100Medicaid