Provider Demographics
NPI:1962417675
Name:CHACONAS, ERIC JAMES (DPT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JAMES
Last Name:CHACONAS
Suffix:
Gender:M
Credentials:DPT
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 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:105 MARINER HEALTH WAY
Practice Address - Street 2:STE 213
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3251
Practice Address - Country:US
Practice Address - Phone:904-217-4259
Practice Address - Fax:904-217-4251
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21730225100000X
FL23527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY137HOtherBCBS
FLAQ374YMedicare UPIN