Provider Demographics
NPI:1235217522
Name:PITLUCK, CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PITLUCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17347
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33318-7347
Mailing Address - Country:US
Mailing Address - Phone:954-370-1053
Mailing Address - Fax:954-370-1533
Practice Address - Street 1:301 NORTHWEST 82ND AVE
Practice Address - Street 2:COLUMBIA OUTPATIENT SURGICAL SERVICES
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324
Practice Address - Country:US
Practice Address - Phone:954-424-1766
Practice Address - Fax:954-370-1533
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5052207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
80240OtherBCBS
80240OtherBCBS
F68886Medicare UPIN