Provider Demographics
NPI:1730400060
Name:CHASTAIN, VERONICA LISSETTE (MD)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:LISSETTE
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1749 DAVID WALKER DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5745
Mailing Address - Country:US
Mailing Address - Phone:352-742-1760
Mailing Address - Fax:352-742-2604
Practice Address - Street 1:1749 DAVID WALKER DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5745
Practice Address - Country:US
Practice Address - Phone:352-742-1760
Practice Address - Fax:352-742-2604
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004367207Q00000X
FLME117565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine