Provider Demographics
NPI:1144574500
Name:CARLOS A CHARLES MD PC
Entity Type:Organization
Organization Name:CARLOS A CHARLES MD PC
Other - Org Name:DERMA DI COLORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-889-5413
Mailing Address - Street 1:115 W 27TH ST
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6217
Mailing Address - Country:US
Mailing Address - Phone:347-889-5413
Mailing Address - Fax:
Practice Address - Street 1:115 W 27TH ST
Practice Address - Street 2:SUITE 1001
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6217
Practice Address - Country:US
Practice Address - Phone:347-889-5413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220104207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100090336Medicare PIN