Provider Demographics
NPI:1366461741
Name:CHAMBLEE, COBRA (DO)
Entity Type:Individual
Prefix:
First Name:COBRA
Middle Name:
Last Name:CHAMBLEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:230 SW 3RD AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-1126
Practice Address - Country:US
Practice Address - Phone:352-618-2107
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8686207Q00000X
FLOS17772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159631003Medicaid
AR5N495Medicare PIN
ARH43888Medicare UPIN