Provider Demographics
NPI:1073802450
Name:MCCALL, CHARISSE (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARISSE
Middle Name:
Last Name:MCCALL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 COMMACK RD STE B
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3459
Mailing Address - Country:US
Mailing Address - Phone:631-467-4653
Mailing Address - Fax:
Practice Address - Street 1:149 COMMACK RD
Practice Address - Street 2:STE B
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3459
Practice Address - Country:US
Practice Address - Phone:631-467-4653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260162207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03918898Medicaid