Provider Demographics
NPI:1770587420
Name:CHARBONNEAU, EUGENE G (DO)
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:G
Last Name:CHARBONNEAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17316 NE STATE ROAD 65
Mailing Address - Street 2:
Mailing Address - City:HOSFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32334-2415
Mailing Address - Country:US
Mailing Address - Phone:850-379-5800
Mailing Address - Fax:850-379-5811
Practice Address - Street 1:17316 NE STATE ROAD 65
Practice Address - Street 2:
Practice Address - City:HOSFORD
Practice Address - State:FL
Practice Address - Zip Code:32334-2415
Practice Address - Country:US
Practice Address - Phone:850-379-5800
Practice Address - Fax:850-379-5811
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2586282Medicaid
FL258628200Medicaid
FL258628200Medicaid
FL181405200936001Medicare Oscar/Certification
FL58034XMedicare ID - Type Unspecified
FLH29995Medicare UPIN