Provider Demographics
NPI:1104863232
Name:EPISALLA, CHARLES W (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:EPISALLA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:30 HATFIELD LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6766
Mailing Address - Country:US
Mailing Address - Phone:845-294-3446
Mailing Address - Fax:845-294-4171
Practice Address - Street 1:39 OLD MONTICELLO RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:NY
Practice Address - Zip Code:12734-5224
Practice Address - Country:US
Practice Address - Phone:845-292-4450
Practice Address - Fax:845-292-4642
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-11-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY184453207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01410035Medicaid
NY01410035Medicaid
F56402Medicare UPIN