Provider Demographics
NPI:1114918778
Name:PRADIEU, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:PRADIEU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:PRADIEU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1743 ATHERTON AVE
Mailing Address - Street 2:1743 ATHERTON AVE
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1744
Mailing Address - Country:US
Mailing Address - Phone:516-424-3216
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:100 SOUTH BLISS AVE
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI-34028Medicare UPIN