Provider Demographics
NPI:1447273826
Name:DACK, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:DACK
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 1:114 MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1179
Mailing Address - Country:US
Mailing Address - Phone:863-293-3909
Mailing Address - Fax:863-293-1909
Practice Address - Street 1:114 MCDONALD ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1179
Practice Address - Country:US
Practice Address - Phone:863-293-3909
Practice Address - Fax:863-293-1909
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36598173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62305AMedicare ID - Type Unspecified
FLD57395Medicare UPIN