Provider Demographics
NPI:1477535805
Name:HAREWOOD, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:HAREWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-5829
Mailing Address - Country:US
Mailing Address - Phone:718-836-0400
Mailing Address - Fax:718-680-0366
Practice Address - Street 1:6802 RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-5829
Practice Address - Country:US
Practice Address - Phone:718-836-0400
Practice Address - Fax:718-680-0366
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00399880Medicaid
NY00399880Medicaid
NY11A481Medicare ID - Type Unspecified