Provider Demographics
NPI:1326054420
Name:BROCATO, CHARLES THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:BROCATO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:APALACHICOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32320-2041
Mailing Address - Country:US
Mailing Address - Phone:850-653-4545
Mailing Address - Fax:850-653-4949
Practice Address - Street 1:111 AVENUE E
Practice Address - Street 2:
Practice Address - City:APALACHICOLA
Practice Address - State:FL
Practice Address - Zip Code:32320-2041
Practice Address - Country:US
Practice Address - Phone:850-653-4545
Practice Address - Fax:850-653-4949
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12314174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY03S0OtherBCBS FL - CARRABELLE
FL8914228900Medicaid
FL8914228900Medicaid