Provider Demographics
NPI:1497934905
Name:HACKETT, CHARLES PETER I (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PETER
Last Name:HACKETT
Suffix:I
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4427 OAK BEACH ASSN
Mailing Address - Street 2:47 LARBOARD CT.
Mailing Address - City:OAK BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11702-4619
Mailing Address - Country:US
Mailing Address - Phone:631-422-1484
Mailing Address - Fax:631-422-9103
Practice Address - Street 1:4427 OAK BEACH ASSN
Practice Address - Street 2:47 LARBOARD CT.
Practice Address - City:OAK BEACH
Practice Address - State:NY
Practice Address - Zip Code:11702-4619
Practice Address - Country:US
Practice Address - Phone:631-422-1484
Practice Address - Fax:631-422-9103
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163238207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
74F32Medicare PIN