Provider Demographics
NPI:1336252444
Name:MCINTOSH, CHARLES B (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:MCINTOSH
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 1:3160 EDGEWOOD AVE W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-2245
Mailing Address - Country:US
Mailing Address - Phone:904-765-5804
Mailing Address - Fax:904-765-0958
Practice Address - Street 1:3160 EDGEWOOD AVE W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-2245
Practice Address - Country:US
Practice Address - Phone:904-765-5804
Practice Address - Fax:904-765-0958
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00066122080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0932138002OtherCIGNA
FL13123OtherHEALTHEASE
FL1055089OtherHUMANA
FL16450OtherTRICARE
FL16450OtherBLUE CROSS /BLUE SHIELD
FL4047696OtherAETNA
FL16450OtherBLUE CROSS /BLUE SHIELD