Provider Demographics
NPI:1740281781
Name:CHARNECO, DALE RAFAEL
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:RAFAEL
Last Name:CHARNECO
Suffix:
Gender:M
Credentials:
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 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:2055 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4461
Practice Address - Country:US
Practice Address - Phone:904-276-4500
Practice Address - Fax:904-276-4160
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15741207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16812YOtherBCBS
FLP00121400OtherRAILROAD MEDICARE
FL16812YOtherBCBS
D53039Medicare UPIN
FL16812XMedicare PIN