Provider Demographics
NPI:1013046341
Name:CHARLES, ELLIS B (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:B
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:63 LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-3008
Mailing Address - Country:US
Mailing Address - Phone:973-895-5062
Mailing Address - Fax:
Practice Address - Street 1:90 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-1050
Practice Address - Country:US
Practice Address - Phone:973-672-2555
Practice Address - Fax:973-672-2529
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1329102084P0800X
NJ25MA051273002084P0800X
GA182842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0866300Medicaid
NJ0866300Medicaid