Provider Demographics
NPI:1114006202
Name:NORDIN, CHARLES WILLIAM
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:NORDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 RHINELANDER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 E 193RD ST
Practice Address - Street 2:MMC FAMILY HEALTH CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-4710
Practice Address - Country:US
Practice Address - Phone:914-637-6801
Practice Address - Fax:718-329-8452
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137790207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00797026Medicaid