Provider Demographics
NPI:1437403607
Name:CHACON, MALIKA M (LMT)
Entity Type:Individual
Prefix:
First Name:MALIKA
Middle Name:M
Last Name:CHACON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15092 NW 147TH DR
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-5305
Mailing Address - Country:US
Mailing Address - Phone:352-317-4713
Mailing Address - Fax:
Practice Address - Street 1:14616 NW 140TH ST
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-6261
Practice Address - Country:US
Practice Address - Phone:352-317-4713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57939305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service