Provider Demographics
NPI:1063472694
Name:FERNICOLA, CHARLES P (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:FERNICOLA
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 1:1145 BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2471
Mailing Address - Country:US
Mailing Address - Phone:609-597-1991
Mailing Address - Fax:609-597-8198
Practice Address - Street 1:1145 BEACON AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2471
Practice Address - Country:US
Practice Address - Phone:609-597-1991
Practice Address - Fax:609-597-8198
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04460500208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3131602Medicaid
NJC59866Medicare UPIN