Provider Demographics
NPI:1275240095
Name:HERTICA, CHARLES PATRICK
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PATRICK
Last Name:HERTICA
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 1:305 HURLEY AVE APT 7F
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6838
Mailing Address - Country:US
Mailing Address - Phone:845-532-8266
Mailing Address - Fax:
Practice Address - Street 1:368 BROADWAY STE 204
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5159
Practice Address - Country:US
Practice Address - Phone:845-481-4728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist