Provider Demographics
NPI:1114000155
Name:MOSKOVITZ, CHARLENE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:MOSKOVITZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 W. FOOTHILL BOULEVARD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-981-4242
Mailing Address - Fax:909-981-0639
Practice Address - Street 1:1317 W. FOOTHILL BOULEVARD
Practice Address - Street 2:SUITE 140
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-981-4242
Practice Address - Fax:909-981-0639
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45670101YM0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50141Medicare UPIN
CA00G456700Medicare ID - Type Unspecified